Every finding on record at Northland Rehabilitation & Health Care Center

Based on observation, interview and record review, the facility failed to properly transfer resident (Resident #1), in a safe manner, when staff did not use two staff members and the sit to stand lift (a mechanical lift used to transfer residents) from bed to shower chair, as directed in the resident's plan of care. The resident fell, resulting in a fracture to the right femur. Facility census was 95. On 04/21/2026 the Administrator was notified of the past noncompliance that began on 03/30/2026. The Administrator immediately began an investigation and audit to identify incorrect care plans. The administrator implemented corrective actions to include re-education for nursing staff to provide care as directed in each resident's care plan and Kardex. An interdisciplinary team meeting was conducted immediately following the incident and included nursing, therapy and leadership review of the event. Weekly audits regarding resident transfers on random shifts were implemented and will be conducted for four weeks then monthly for three months to ensure compliance. Results will be reviewed in quality assurance meetings for ongoing compliance. The noncompliance was corrected on 03/31/2026. Review of the facility's undated policy titled, Fall Prevention, showed:-The purpose of the Fall Management Program is to develop, implement, monitor and evaluate an interdisciplinary team falls prevention approach and manage strategies and interventions that foster resident independence and quality of life;-The Fall Management Program promotes safety, prevention, and education of both Staff and residents; -The Facility shall ensure that a Fall Management Program will be maintained to reduce the incidence of falls and risk of injury to the resident and promote independence and safety;-A fall is the unintentional coming to rest on the ground, floor, or other lower level; -Serious injury includes but not limited to fracture;-Residents found to be at high risk for falls are placed on the Fall Program, and Interventions are implemented to meet individual needs;1. Review of Resident #1's electronic medical record showed diagnoses included: Multiple Sclerosis (a chronic autoimmune disease affecting the central nervous system that damages the myelin sheath protecting nerve cells, leading to a range of neurological symptoms like vision problems, numbness, weakness, balance issues and cognitive difficulties), anxiety disorder (a mental health disorder characterized by severe, ongoing anxiety that interferes with daily activities), fracture of shaft of right femur, history of falls. Review of the quarterly Minimum Data Set (MDS, a federally mandated assessment completed by staff) dated 03/03/26 showed:-He/She scored 14 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly residents) indicating no cognitive decline;-He/She displayed no behaviors during the assessment period;-He/She had impairment to both lower extremities and used a wheelchair for mobility;-He/She required moderate assistance with Activities of Daily Living (ADLs);-He/She was dependent on staff in transferring;-He/She had one fall since the last MDS assessment with major injury.Review of the comprehensive care plan, dated 03/31/26, showed:-Interventions related to risk for falls, multiple sclerosis, ADLs;-Before the fall on 03/31/26, he/she required the assistance of two staff members and the sit to stand lift for transfers;-The care plan was updated on 03/31/26 that the resident now required the assistance of two staff members and the Hoyer lift (a lift that lifts the resident completely off of the ground with a sling);-Interventions also included the resident has a history of manipulation of staff, telling them he/she can do more than he/she is physically able to do. Review of the resident's emergency room medical record dated 03/31/26 showed:-The resident was transferred to the emergency room by Emergency Medical Services (EMS) on 03/31/26 at 6:30 P.M. from the facility; -The resident had a fall at the facility and was complaining of pain in the right leg; -The emergency room performed x-rays of the resident's right knee and right pelvis/hip; -The x-ray showed the resident had a nondisplaced right distal femur fracture (a break in the lower part of the thighbone just above the knee, where the bone cracks but remains in proper alignment without significant shifting); -The resident was placed in an immobilizing brace for the right knee and discharged back to the facility;-He/She was to be non-weight bearing on the right leg until he/she followed up with the orthopedic surgeon. Review of the resident's progress notes on 04/21/26 showed:-The resident was seen by the orthopedic surgeon on 04/19/26;- The orthopedic surgeon gave an order for the resident be weight bearing as tolerated and approved to bear weight during transfers;-The resident was to stop using the immobilizer to the right knee, and to work on range of motion;-The resident was to follow up with the orthopedic surgeon in four weeks.-On 03/31/26, the resident was being transferred by Certified Nurses' Assistant (CNA) A from the bed to the shower chair at 11:30 A.M. when CNA A lowered the resident to the floor;-Licensed Practical Nurse (LPN) A was called to the room to assess the resident;-LPN A reported the resident was sitting on the floor with his/her legs extended in front of him/her, leaning against the side of the bed;-CNA A reported to LPN A that he/she was transferring the resident alone;-The shower chair moved and CNA A had to lower the resident to the floor;-LPN A assessed the resident, and he/she did not appear to have any acute injuries at that time;-The resident told LPN A that his/her legs gave out during the transfer;-CNA A reported the shower chair was locked;-Later, the resident complained to LPN A that he/she was having pain in the right knee;-LPN A notified the nurse practitioner, who ordered for the resident to have x-rays done of his/her knee;-X-ray results showed an acute non-displaced fracture of the distal femur;-The resident was sent to the local hospital for evaluation;-He/She returned to the facility with an immobilizer to the right knee and a follow up appointment with the orthopedic surgeon. During an interview on 04/21/26 at 9:17 A.M., the resident said:-CNA A entered the resident's room that morning to assist him/her with a shower;-CNA A brought the shower chair into the room, set it up next to the bed and locked the wheels;-CNA A used a gait belt to transfer the resident;-CNA A was alone and no other staff were assisting with the transfer;-The resident stood and was beginning to turn toward the shower chair when his/her legs gave out and CNA A had to lower the resident to the floor; -The resident came to rest on floor with his/her right leg underneath him/her;-The resident asked CNA A to move the resident's right leg from underneath him/her to out in front on him/her;-The resident did not know how staff were supposed to transfer him/her, but that other staff have used the sit to stand life and two people; -Later in the day, the resident began having pain in the right knee and was sent to the emergency room for x-rays;-The x-rays showed a fracture in his/her right femur;-The resident came back from the emergency room with a brace to his/her knee. During an interview on 04/29/26 at 12:59 P.M., CNA A said: -On 03/31/26, CNA A was transferring the resident from the bed to the shower chair;-CNA A situated the shower chair near the bed and locked all four wheels;-He/She began to assist the resident transferring from the bed to the shower chair, using a gait belt;-As he/she was assisting the resident, the shower chair moved;-CNA A was unable to move the resident back to the bed, and slowly assisted the resident to sitting on the floor;-CNA A does not recall the exact position the resident's legs were in when he/she was lowered to the floor, but does recall readjusting the resident's legs to in front of the resident to make the resident more comfortable;-CNA A called for the charge nurse to assess the resident; -CNA A had not worked with the resident in quite some time;-CNA A believed the resident was a one person assist with a gait belt; -The resident told CNA A that he/she could transfer with only one staff member and no lift; -CNA A was aware that the resident's transfer needs can be found in the care plan and Kardex;-The staff can also ask the charge nurse if they are unsure how a resident should be transferred;-CNA A did not check the resident's care plan or Kardex to determine the resident's transfer needs;-He/She should have checked the care plan and Kardex before he/she tried to transfer the resident. During an interview on 04/29/26 at 12:09 P.M., the Director of Nursing (DON) said when transferring residents, he/she expected the staff to always follow the comprehensive care plan, Kardex instructions and recommendations from the therapy staff. If the resident tells the staff something that does not match the care plan, he/she expected the staff to check the care plan or check with the charge nurse before proceeding with transferring the resident. Nursing staff have been re-education to follow the care plan and Kardex. During an interview on 04/21/26 at 9:45 A.M., the Administrator said it was his/her expectation that staff will follow the resident's care plan for the safest and most appropriate way to transfer the resident. She conducted an investigation into the incident and implement corrective actions to address the facility failure. During an interview on 04/29/26 at 12:34 P.M., the resident's physician said:-Staff should always follow the direction of the comprehensive care plan and/or direction of the therapy staff when transferring a resident; -If a resident required the assistance of two staff members to transfer, a staff member should never attempt this alone; -If a staff member is unsure of how to transfer a resident, or if a resident tells the staff something different than what is on the care plan, the staff should always check with the charge nurse before attempting to transfer the resident. Intake 2970142

Based on observation, interview, and record review, the facility failed to serve meals in accordance with facility policy and scheduled mealtimes. This affected two of five sampled residents (Resident #1 and Resident #2) The facility census was 97. Review of facility undated policy titled Dining Service Mealtimes, included, there should be no more than 14 hours between the time the evening meal is offered, and the breakfast meal is offered, or 16 hours if a substantial evening snack is provided. A substantial evening snack included a protein source and a fruit or bread source.Review of the facility mealtimes posted in the hallways and dining room showed:-Breakfast is served at 8:30 A.M.-Lunch is served at 12:30 P.M.-Dinner is served at 5:30 P.M.1.Review of resident's care plan, dated 12/26/25, showed the resident had potential for nutritional problems and had intervention to provide and serve diet as ordered by the physician. Review of Resident #1's admission Sheet, dated 12/29/25, showed diagnosis of acute osteomyelitis left ankle (rapid bone infection), stroke, moderate protein-calorie malnutrition, diabetes, dementia, depression, PTSD, heart disease, and kidney disease and was admitted to the facility on [DATE].Observation and interview with Resident #1 and CNA A on 12/29/25 at 9:50 A.M. showed: - The resident said he/she was admitted to the facility two days ago and this was the second day in a row that staff had not brought him/her breakfast. He/She was very hungry, and it makes him/her feel like the staff doesn't care when meals are not served. Observation showed no breakfast tray in the residents room;- At 9:56 A.M. CNA A entered the room to remove the breakfast tray but there was nothing to remove. The staff member said he/she did not realize that resident had not been served breakfast and he/she will go to the kitchen to get him/her a breakfast meal;- At 10:29 A.M. CNA A brought the resident a breakfast tray, 2 hours late.2. Review of Resident #2's admission Sheet, dated 12/29/25, showed diagnoses of a fractured left femur, cognitive communication deficit, osteoporosis (bone disease), GERD (acid reflux), and an anxiety disorder.Review of the resident's care plan, revised 12/22/25, showed:- Resident had GERD, avoid overeating, provide small frequent meals rather than three large ones;- Resident had potential nutrition risk related to anxiety. Provide and serve diet as ordered. Observation on 12/29/25 at 10:16 A.M., showed breakfast delivered to the resident's room over 1.5 hours late.During an interview on 12/29/25 at 1:30 P.M., the resident said he/she had gotten a breakfast meal late, after 10:00 A.M. the past two days. He/she would prefer to be served around 8:30 A.M. because when breakfast is served late, it runs too close to the next meal which is lunch time that starts at 12:30 P.M. It makes him/her feel like he/she has been forgotten by the staff and gives him/her anxiety because he/she isn't sure if the staff are going to deliver the meal to him/her that day.During an interview on 12/29/25 at 12:45 P.M., Certified Nursing Assistant (A) said:- The kitchen staff take meal tickets to the Certified Medical Technicians (CMT) for breakfast and lunch and the CMTs find out what the resident wants to eat for those meals. The tickets are then turned back into the kitchen. When staff members deliver trays to residents, they check the tickets to what is on the tray and to make sure it's accurate. When new residents are admitted , staff are usually notified through admission paperwork the same day. When he/she does his/her oncoming walk through with the off going staff member on the shift they both will go room to room and update resident status from the previous shift. That's when he/she will see that there is a new resident and they are accounted for and cared for by the staff without anyone falling through the cracks and getting missed for meals. CMT A was not sure why Resident #1 and Resident #2 received their breakfast meals late.During an interview on 12/29/25 at 1:15 P.M., the Dietary Manager (DM) said:- New admission residents will trigger an email or message the same day to the DM. Within 48 hours the resident will be asked about likes and dislikes for meals and have this entered into their electronic medical record so meal tickets will print out properly. Until that time, the nursing staff will use blank meal tickets to get the resident's order for each meal and keep the kitchen informed if the resident is eating in their room or in the dining room. If a resident doesn't show up in the dining room, the kitchen staff will catch this because they do an audit of residents on site versus the residents served during the meal right after the dining room has completed being served, which is normally 30 minutes after the start of the meal. Those not attending the dining service will automatically get a hall tray delivered to their room. Residents should receive their meal within an hour of the official start time for each meal. During an interview on 12/29/25 at 2:10 P.M., the Administrator said breakfast is at 8:30 A.M, lunch at 12:30 P.M., and dinner is at 5:30 P.M. He/she expects residents to receive their meal within one hour of the beginning of each meal service, even if that meal is being delivered with hall trays and this included meals for all newly admitted residents. Intake 2692290

Based on observation, record review, and interviews, the facility failed to store, prepare and serve food in accordance with professional standards of food service safety when staff failed to discard expired leftovers in the refrigerator, failed to wear beard nets and hand wash while working in the kitchen, failed to maintain proper standards of cleanliness and storage in the kitchen area, and failed to take accurate temperature readings of cooked food items. This affected all residents by putting them at risk for a food borne illness. The facility census was 95. Review of facility policy Monitoring Food Temperatures for Meal Service, undated, showed:- Food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures;- Prior to serving a meal, food temperatures will be taken and documented for all hot and cold foods to ensure proper serving temperatures. Any food item not found at the correct holding/serving temperature will not be served but will undergo the appropriate corrective action;- The temperature of each food item will be recorded on the Foot Temperature Log. Foods that require corrective action (such as re-heating) will have the new temperature recorded with a circle around it next to the original temperature;- When taking temperatures, the thermometer is inserted in the thickest part of the food, not touching any part of the container, and held until the maximum or minimum temperature is reached;- Food temperatures of hot foods on room trays at the point of service are preferred to be at 120 degrees Fahrenheit or greater to promote palatability for the resident;Review of facility policy Handling Leftover Food, undated, showed:- Once food has cooled to 41 degrees Fahrenheit or less it is sealed tightly and labeled to identify the contents and has a use by date that is clearly visible;- Leftover foods stored in the refrigerator shall be wrapped, dated, labeled with a use by date that is no more than 72 hours from the time of first use;- Refrigerated leftovers stored beyond 72 hours shall be discarded;- Opened canned food items shall be transferred to a clean, closed container for storage;Review of facility policy Food Storage (Dry, Refrigerated, and Frozen), undated, showed:- Food shall be stored on shelves in a clean, dry area, free from contaminants;- All food items shall be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded;- Keep potentially hazardous foods out of the temperature danger zone (41 degrees Fahrenheit - 135 degrees Fahrenheit);Review of facility policy Hair Restraints, undated, showed:- Hair restraints shall be worn by all Dining Services staff when in food production, dishwashing areas or when serving food from the steam table;- Hair restraints, hats, and/or beard guards shall be used to prevent hair from contacting exposed food. - Any facial hair that is longer than the eyebrow shall require coverage with a beard guard in the production and dishwashing areas;Observation on 7/21/25 at 9:38 A.M., showed:Kitchen Walk-in Freezer:- Ice forming and coming down from the back of the condenser in the freezer;- Ice chunks on the floor of the freezer;- One box of frozen food sitting on the floor;- Condensation on the floor in a puddle in front of the freezer door;Walk-in Refrigerator:- Leftover food item not labeled or dated;- Mushy carrot leftovers undated;- Egg whites dated 7/16/25 opened and resealed, leftover expired and not discarded;- Unlabeled and undated meat in a see-through plastic wrap in a pan defrosting on the bottom rack with yellow liquid surrounding the package in the pan;- Italian dressing container opened but not resealed;- Heavy whipping cream opened 7/11/25 and resealed, expired but not discarded;- Grime and dirt under the racks on the floor throughout the refrigerator;- Unbroken eggs on the floor under the racks;Bulk Storeroom Pantry:- Browning sauce opened with no date annotated;- Bulk tomato catsup stored 4/18/25, opened and resealed with no open date;- Eight bowls of unlabeled or dated dry cereal for individual use on rack in pantry;- Top of bulk sugar container had food stains and crystallized substance on the handle;- Inside of bulk sugar container are two black unknown specs of foreign material in the sugar;Chest Refrigerator:- Black specs and moldlike substance inside of the unit along the center section covering an eight inch area;- Cherry Tomatoes leftover dated 7/17/25, expired and not discarded;Kitchen Area:- Dish holders next to steam line are caked with food debris and stains throughout the interior of the fixture;- Dietary Aide (D), with a facial beard longer in length than an eyebrow, working in the dishwashing and kitchen area without a beard net donned;During an interview on 7/21/25 at 9:50 A.M., Dietary Aide (D) said:- Was not sure why he/she had to wear a hat in the kitchen and did not know the requirements for a beard net in the kitchen;During an interview on 7/21/25 at 9:55 A.M., the Dietary Manager (DM) said:- She had not informed the maintenance department that the condenser in the walk-in freezer was leaking and causing ice to form;- Leftovers are kept for a maximum of three days and then are thrown out; Observation in the Dining room on 7/22/25 at 7:33 A.M., showed:- Buildup of algae and mold like growth in the ice machine drain;Observation in the Kitchen on 7/22/25, showed:- DM resigned from the position yesterday with no person appointed to take over;- 9:50 A.M. Trash can at handwashing station overflowing with trash;- Refrigerator had unlabeled liquid in a steel container and unlabeled meat in a container;- Sink near the ice machine underneath the counter and piping contains eight inch area of black grime and plastic trash. Multiple drains have food debris and trash in them around the dishwasher and kitchen sinks;- 10:30 A.M. Dietary Dishwasher (A) came into kitchen from break and put on gloves to work in the dishwashing area without first washing his/her hands;- 10:37 A.M. Puree carrots completed and placed into the warmer, no temperature taken;- Horizontal surfaces above plate holder near steam line had food debris and stains;- Food warmer next to stove had corner of glass cover broken off (two square inch area) and missing on front side of warmer;- Pans in the clean storage rack had oily film around storage surface edges;- Chest refrigerator had a block of cheese dated 7/21/25 not sealed;- 11:00 A.M. Chicken pot pie mixture of gravy, chicken, and vegetables poured into two deep steel containers with defrosted pre-made crust lining the bottom and sides of the container. Contents covered with a top layer of crust and placed into the oven without any temperatures taken;- Mold like substance on ventilation diffusers in the overhead throughout the kitchen;- 11:13 A.M. Puree chicken pot pie container moved from the oven to the warmers with no temperature taken;- 11:22 A.M. Mashed potatoes completed cooking and placed in the warmer with no temperatures taken;- Condensation from the overhead diffusers falling at 1 drop per 3 minutes from various locations in the kitchen;- 11:35 A.M. Carrots with brown sugar added to the steam line from the stove. Dietary [NAME] (A) placed a meat thermometer into the carrots for two seconds and the temperature bounced from 180 degrees Fahrenheit to 215 degrees Fahrenheit without stabilizing;- 11:37 A.M. Puree carrots were removed from the warmer and placed onto the steam table without any temperatures taken;- 11:50 A.M. Puree Chicken Pot Pie from the steam line was temperature checked and recorded as 110 degrees Fahrenheit which is in the danger zone for hazardous food items such as raw chicken. Food item was taken to the stove for re-heating in a skillet;- 11:55 A.M. Chicken Pot Pie main course was removed from the oven and placed on the steam line. Temperature taken by the state surveyor registered at 151 degrees Fahrenheit. Dietary [NAME] (A) took the temperature for two seconds and got 169 degrees Fahrenheit; Dietary [NAME] (A) after being asked to re-temp the main course and hold the thermometer for greater than ten seconds without touching the metal pan recorded a temperature of 153 degrees Fahrenheit. Dietary [NAME] (A) then removed both pans of Chicken Pot Pie and put them back in the oven for further cooking;- 12:08 P.M. Dietary Aide (C) placing food of plates while wearing gloves and a hair net and holding a hair net in one of his/her hands. The hair net being came in contact with the surface of plates and some food items that were placed on plates;- 12:10 P.M. Dietary Aide (E) cooking at the stove with hair net not covering his/her moustache;- 1:04 P.M. Dietary Server (A) with beard, loading food trays in the kitchen onto hall carts not wearing a beard net;During an interview on 7/22/25 at 1:15 P.M., Dietary [NAME] (A) said:- The puree and main course of Chicken Pot Pie needed to be cooked to a temperature of 165 degrees Fahrenheit due to the chicken in the product;Observation on 7/22/25 at 1:22 P.M., showed:- Food Cart with test tray arrives at 160 Hall;- Test hall tray containing pureed carrots measured 102 degrees Fahrenheit;- Test hall tray containing pureed chicken pot pie measured 106 degrees Fahrenheit; During an interview on 7/24/25 at 9:30 A.M., the Maintenance Supervisor said:- He was not aware of the condenser leak in the freezer, and this would be something that he would repair or arrange for it to be fixed if he was notified;- He was never notified about mold growing on the ventilation diffusers in the kitchen. Due to the height of these vents, maintenance would go in and clean these when notified or help kitchen staff do this safely;- His department works off of a work order system to track and schedule repairs;During an interview on 7/24/25 at 1:30 P.M., the Administrator said:- Water should not be leaking from the back of the freezer condenser and ice chunks should not be on the floor of the freezer;- Food boxes should not be stored on the floor of the freezer;- Leftovers may be reheated once and discarded according to the facility's policy;- Leftovers should be labeled and dated;- Defrosting meat lying in a tray should be labeled and dated;- Opened containers should be resealed when put back into the refrigerator;- She would not expect to see grime or dirt under the storage racks throughout the refrigerator;- There should be no food on the floor under the racks;- There should be no black specs in the bulk sugar;- There should be no black specs or growth on the inside surfaces of the chest refrigerator;- [NAME] nets are required in the kitchen according to the facility's policy;- She would not expect the plate holder to have food stains on the surfaces of the unit;- Temperatures for foods served should follow facility policy;- Initial temperature checks should be taken right before food is served and the temperatures should follow facility policy;- Two seconds is not long enough to properly measure the temperature of food cooked, measurements should follow manufacturers guidelines;- She would not expect condensation and mold like growth on the ventilation diffusers in the kitchen overhead;- She would expect kitchen staff returning from their break to wash their hands upon entering the kitchen;

Based on observations, interviews, and record review, the facility failed to ensure staff discarded expired medications and biologicals stored in the rehabilitation nurse's medication room. The sample size was 19 residents. The facility census was 95. Review of the facility's undated policy, Medication Administration, showed:Adherence to this medication administration policy is essential to ensure the well-being and safety of the residents. All staff members are expected to follow these guidelines strictly and to report any issues or deviations from the policy. Continuous improvement and open communication are encouraged to uphold best practices in medication administration. Residents who self-administer must have a profile only medication administration record (MAR) which lists their medications and indicates that they self-administer.Medications should be stored in a secure, locked area with restricted access to authorized personnel only.Expired or discontinued medications should not be stored and should be disposed of according to proper procedures. Observation and interview on 7/23/25 at 12:12 P.M., in the rehabilitation nurse's medication room showed:- One unopened bottle of mucus relief, expired 5/25.- One opened bottle of mucus relief, expired 9/24.- Three unopened bottles of Aspirin 325 mg., expired 9/24.- One unopened bottle of saline nasal spray, expired 1/25.- One opened bottle of mucus relief, expired 4/25.- Two unopened bottles of mucus relief, expired 5/25.- Two unopened bottles of mucus relief, expired 4/25.- Two unopened bottles of glucose tablets expired 11/24.- Licensed Practical Nurse (LPN) A said staff should not use the expired meds, the expired medications should be disposed. He/she was not for sure who was responsible to check the medication room for expired medications.During an interview on 7/24/25 at 11:19 A.M., the Director of Nursing (DON) said:- There should not be any expired medication in the medication room.- The nurse managers should be checking the medication rooms for expired medications at least monthly.

Based on observation, interview and record review, the facility failed to provide respiratory care and services in accordance with professional standards of practice, by not following physician orders regarding oxygen maintenance of tubing and/or oxygen flow rate on four of the 21 sampled residents, #30, #82, #107 and #108. The facility census was 95.Review of the facility's policy Oxygen Administration dated 3/20/25 showed:-to verify that there is a physician's order for oxygen administration;-to check the tubing connected to the oxygen cylinder or concentrator to assure that it is free of kinks;-to turn on the oxygen and start the flow of oxygen at the rate ordered.Review of the facility's policy Use of Oxygen During Transports dated 3/2025 showed:-If a continuous order, oxygen will be provided to the resident at all times including transports between locations within the facility and also outside of the facility.-Adjust the cylinder flow meter to the ordered amount of oxygen supply by liters.1. Review of Resident #30's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/29/25 showed:-Cognition Intact;-History of a stroke affecting the left side of her body;-Kidney Disease;-Heart rhythm problems;-Cardiac pacemaker-Unsteadiness Observation on 7/21/25 at 10:05 A.M., showed oxygen tubing was out of date, it was dated 7/6/25, eight days overdue. Observation on 7/22/25 at 10:05 A.M., showed oxygen tubing was out of date, it was dated 7/6/25, nine days overdue. Observation on 7/23/25 at 10:05 A.M., showed oxygen tubing was out of date, it was dated 7/6/25, ten days overdue. Review of the current orders showed no order for oxygen.Review of the Care Plan dated 8/19/24 showed no order for oxygen.During an interview on 7/21/25 at 10:05 A.M., the resident said he/she was not aware that tubing was to be changed.2. Review of Resident #82's Quarterly Minimum Data Set (MDS), dated [DATE] showed:-Cognition moderately intact;-Acute respiratory failure;-Had sleep apnea.Review of the Care Plan dated 7/3/25 showed:-Resident had altered respiratory status and difficulty breathing at night related to sleep apnea;-Monitor document changes in orientation, increased restlessness, anxiety, and air hunger;-Monitor for signs and symptoms of respiratory distress and report to the medical doctor as needed;-No care plan interventions related to oxygen therapy.Review of the Physician Orders dated 7/2/25 showed:-Oxygen with nebulizer at 4 Liters continuous or PRN (as needed); -Change nebulizer and tubing weekly on Wednesdays;-Clean oxygen concentrator filter and allow to air dry weekly;-Change oxygen tubing weekly every night shift on Wednesdays.Observation on 7/21/25 at 10:00 A.M., showed oxygen on at 4L per Nasal cannula, tubing undated.Observation on 7/22/25 at 11:00 A.M., showed oxygen on at 4L per Nasal cannula, tubing undated.Observation on 7/22/25 at 2:00 P.M., showed oxygen on at 4L per Nasal cannula, tubing undated.Review of the medication administration record showed no documentation of oxygen tubing dated or changed. Review of the treatment administration record showed no documentation of oxygen tubing dated or changed.3. Review of Resident #107's Face Sheet, dated 7/16/25 showed:-Acute respiratory failure;-History of chronic obstructive pulmonary disease (air exchange disorder) and pulmonary edema (extra fluid in the lung tissue);-Heart failure.Review of the Care Plan dated 07/21/25 showed:-Give respiratory medications as ordered and monitor for any side effects and their effectiveness;-Give oxygen therapy as ordered by the physician;-Elevate the head of the bed during episode of difficulty breathing;-Monitor for difficulty breathing on exertion, remind the resident not to push beyond endurance level;-Monitor for signs and symptoms of acute respiratory insufficiency: anxiety, confusion, restlessness, shortness of breath, cyanosis (blue tint to nails, skin), and somnolence;-Monitor for signs of a respiratory infection.Review of physician orders dated 7/16/25 showed:-Clean the oxygen concentrator filter with water and allow it to air dry weekly;-Oxygen at 3 L at rest and 4 L with activity every day and night shift;-Oxygen tubing to be changed weekly in the evening every Wednesday.Observation on 7/21/25 at 11:00 A.M., showed:-Oxygen tubing on concentrator labeled under the name of a different resident.-Oxygen tubing on concentrator dated 7/9/25 (before resident was admitted ).Observation on 7/22/25 at 9:00 A.M., showed:-Oxygen tubing on concentrator labeled under the name of a different resident.-Oxygen tubing on concentrator dated 7/9/25 (before resident was admitted ).Observation on 7/23/25 at 9:30 A.M., showed:-Oxygen tubing on concentrator labeled under the name of a different resident.-Oxygen tubing on concentrator dated 7/9/25 (before resident was admitted ).During an interview on 7/21/25 at 11:00 A.M., Resident #107 said he/she needed to wear oxygen at all times.4. Review of Resident #108's Face Sheet, dated 7/16/25 showed:-Respiratory failure;-Chronic obstructive pulmonary disease;Review of Resident #108's Care Plan, dated 7/17/25 showed oxygen via nasal prongs at 4 L continuously humidified.Review of the Physician Orders dated 7/16/25 showed:-Change oxygen tubing weekly in the evening every Wednesday;-Clean oxygen concentrator filter with water and allow to air dry weekly in the evening every Wednesday;-Oxygen at 4L per nasal cannula every day and night shift.Review of the medication administration record showed no documentation of oxygen tubing changed. Review of the treatment administration record showed no documentation of oxygen tubing changed.Observation on 7/21/25 at 3:00 P.M., showed no date on oxygen tubing.Observation on 7/22/25 at 9:00 A.M., showed no date on oxygen tubing.Observation on 7/23/25 at 1:30 P.M., showed no date on oxygen tubing.During an interview on 07/21/25 at 3:00 P.M., Resident #108 said he/she just arrived here so doesn't know if they change the oxygen tubing.During an interview on 7/23/25 at 4:30 P.M., CNA B said:-nurses regulate the oxygen;-if the nasal cannula is not on right it is adjusted.During an interview on 7/24/25 at 09:00 A.M., LPN C said:-nurses adjust the oxygen;-if the resident shows symptoms that oxygen needs increased, the provider is contacted.During an Interview on 7/24/25 at 08:45 A.M., the DON, said:-nursing adjust the flow rate as needed and per doctor order;-oxygen requires a physician's order;-tubing should be changed and dated as per the orders;-tubing should be changed and dated per policy and procedure.During an Interview on 7/24/25 at 11:00 A.M., the Administrator said:-nursing adjust the flow rate as needed and per doctor order;-oxygen requires a physician's order;-tubing should be changed and dated as per the orders;-tubing should be changed and dated per policy and procedure.

Based on observation, interview, and record review, the facility failed to promote an environment respectful of the rights of each resident to make choices about significant aspects of their lives when staff did not provide satisfactory meals or offer evening (HS) snacks to four residents (Resident #5, #60, #71, and #76), failed to honor resident menu choices for two residents (Resident #33 and #55), failed to serve meals according to one resident's preferences (Resident #8), failed to offer to one resident menu items prepared for the meal (Resident #11), and failed to offer condiments to the alternate dining room. This affected eight of 19 residents sampled. The facility census was 95.Review of the facility policy, Resident Rights, dated 12/2024, showed each resident residing in this community has the right and will be afforded the right to a dignified existence and self-determination. No facility policy was provided regarding snacks. No facility policy was provided regarding resident meals. 1. Review of Resident #5's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 07/11/25, showed: - Cognitive skills intact; - Setup or clean up assistance required by nursing staff with eating; - Dependent on facility staff for mobility and transfers; - Diagnoses included: Hip fracture, depression, and thyroid disorder. Review of the Comprehensive Care Plan, dated 07/09/25, showed: - Potential/actual impairment to skin integrity and nursing staff are required to encourage good nutrition and hydration to promote healthier skin; - Dietary preferences will be honored and Resident prefers snacks between meals; - An activities of daily living (ADL's) self-care performance deficit and nursing staff participation are required with bathing, mobility, dressing, and eating. During an interview on 07/21/25 at 09:50 A.M., the Resident's spouse said: - Three days last week Resident got toasted cheese sandwich and fries; and many times meals do not have drinks; - The staff might bring snacks if asked to, but the staff does not just bring them; During an interview on 07/22/25 at 09:39 A.M., the Resident said: -Food sometimes looks like you don't want to eat it. The broccoli is cooked until it's mush; -Staff forget to put milk on the trays or spoons or straws and you don't always get what you order; -He/She was upset for receiving a grilled cheese three days in a row for lunch; -He/She was upset that at 9:40 A.M breakfast had not been served and had no snack last night; -He/She had to ask for snacks and staff don't bring snacks around room to room; -Does not normally get condiments; -He/She feels mistreated and disrespected; During an interview on 07/24/2025 at 07:30 A.M., the Resident said the lunch meal yesterday was supposed to be sweet and sour pork, but it didn't taste like pork; Staff will not bring snacks to the rooms and residents have to ask, but then the staff won't come back so he/she stopped asking for snacks. 2. Review of Resident #60's Quarterly MDS, dated [DATE], showed: -Cognitive skills intact; -Independent with eating; -Diagnoses included: Renal failure (condition where the kidneys lose the ability to adequately filter waste and excess fluids from the blood) requiring Hemodialysis (medical procedure that filters a person's blood to remove waste products and excess fluid when the kidneys are unable to do so), Diabetes, and High Blood Pressure. Review of the Comprehensive Care Plan, dated 04/28/25, showed: -Congestive heart failure diagnosis and nursing staff are required to encourage adequate nutrition and offer small frequent feedings; -Potential/actual nutritional problem related to renal failure/dialysis and nursing staff are required to provide and serve diet as ordered and monitor, record, report signs or symptoms of malnutrition to provider; -At risk for low blood pressure and nursing staff are required to encourage adequate fluid intake and a healthy diet. During an interview on 07/21/25 at 11:30 A.M., the Resident said: - Resident rooms near the nurses station get snacks provided but we don't get snacks down the hall, we have to ask; - He/She feels with the amount of money the residents pay to live at the facility, the facility staff should offer snacks; - The staff don't bring water by often and are supposed to bring ice water at least each shift; - The food tastes bad, smells bad, and is cold by the time it gets delivered to the room; - The hot food is not hot, or the food is cold and complaining to the staff doesn't do any good; - He/She feels going to resident council meetings does no good and the facility staff doesn't listen because we are old; - His/Her family brings in food for them both because the food here tastes terrible. During an interview on 07/24/2025 at 08:00 A.M., the Resident said: -His/Her room is always last to have room food trays delivered, it is always late, and cold. Dinner was served last night around 08:00 P.M.; -The food tastes terrible; -The portion sizes are too small; -The staff are to provide ice morning, noon, and night. The water cups have my name on it and he/she does not know when it was last washed. -The weekends are lousy with the food being terrible and cold and he/she hates to know the weekend is coming; -He/She is never offered a snack; -There is new staff all the time, and no consistency with the staff; -His/Her family brings food on the weekends; 3.Review of Resident #71's Annual MDS, dated [DATE], showed: -Cognitive skills intact; -Setup or clean up assistance required by staff for eating; -Dependent on staff for mobility and transfers; -Diagnoses included: Hemiplegia (condition characterized by the paralysis of one side of the body, affecting the arm, leg, and sometimes the face), diabetes, and high blood pressure. Review of the Comprehensive Care Plan, dated 06/09/25, showed: -Potential nutrition/hydration risk related to diagnoses and nursing staff are required to provide and serve diet as ordered and monitor, record, and report signs and symptoms of malnutrition to provider; -Resident had diabetes and staff are required to monitor, document, and report signs and symptoms of low and high blood sugar; -Potential/actual impairment to skin integrity related to decreased mobility and staff are required to encourage good nutrition and hydration to promote healthier skin. During an interview on 07/21/25 at 02:40 P.M., the Resident said: -Food needs to be improved dramatically, there is a food council in addition to the resident council, but administration doesn't do anything. The same complaints about the food are every month; -The staff leave snacks at the nurse's station. Nursing staff used to take them around room to room but now the snacks are just left at the nurse's station and the nurses take the snacks or some residents take a lot for them selves; -Food had no taste, no seasonings, and is very bland; -The hot food is cold and the cold food is warm; -He/She feels that food is one of the only treasures he/she had anymore. During an interview on 07/24/2025 at 07:45 A.M., the Resident said: - Breakfast had no taste and was cold. - Food temperatures are a problem with the hot food cold and cold food warm, everything is tough (meat), and is never served on time; - The facility changed the meal times without telling us to 08:00 A.M., 12:00 P.M., and 05:00 P.M., which makes him/her feel terrible and disrespected; - The Administrator took everything away, like soda- pop and snacks and the staff does not pass snacks around to the residents; - The facility will have snacks at the nurse's station but once he/she is in bed, he/she is confined to bed and depends on staff to offer snacks; - He/She feels angry that he/she can't get a snack if wanted one. 4.Review of Resident #76's Quarterly MDS, dated [DATE], showed: -Cognitive skills intact; - Setup or clean up assistance required by staff for eating; - Substantial assistance required by staff for transfers and mobility; - Diagnoses included: High blood pressure, osteoarthritis, and depression. Review of the Comprehensive Care Plan, dated 04/30/25, showed: -Potential nutrition/hydration risk related to diagnoses and nursing staff are required to provide and serve diet as ordered and monitor, record, and report signs and symptoms of malnutrition to provider; - Potential impairment to skin integrity related to impaired mobility and incontinence and staff are required to encourage good nutrition and hydration to promote healthier skin; -Staff are required to monitor, record, and report to nurse loss of appetite, refusal to eat, and weight loss. During an interview on 07/21/25 at 10:15 A.M., the Resident said: - He/She doesn't like the food because it was usually too cold and had no taste; . He/She wished the staff would pass snacks around because it's not easy to go get them; During an interview on 07/24/2025 at 08:00 A.M., the Resident said: -The food is terrible and the servings are too small. There's no salt or seasonings, it comes late, and is usually cold, which depresses and makes him/her unhappy. The dessert is just a tiny piece in a cup; -The staff don't pass fresh ice and water. They just refill the cups and don't wash them which makes me not want to be here; - His/Her family brings in food two to three times a week. During the resident group interview on 07/22/2025 at 11:01 A.M., the residents said: - Food temperatures are a problem as well as the portion size. The residents feel they are adults getting kiddie sized portions, the hot food is cold, and most are hungry after eating; - They aren't getting snacks passed to them, even after speaking with the Director of Nursing, who told them are to be passed three times a day; - Snacks used to get passed but they don't now. Staff had a bucket at the nurses station and wheelchair people can't see the snacks in the bucket. Unless the residents can go to nurses station the resident's don't get snacks; - The counsel does not like Kool aid, it is too sweet, that is for children, and also there are too many diabetics; - The meat is tough, meals are usually served late, and always served cold; - There are few choices offered, but always sandwiches and the staff don't ask the residents about choices. The resident's have to send a note to the kitchen; - 13 of the 24 residents said they have requested a snack, and the staff don't bring one; - 17 of the 24 residents wanted snacks brought around; - The residents do not like the use of Styrofoam cups and coffee cups with no handles. During an interview on 07/24/2025 at 08:55 A.M., Certified Nursing Assistant (CNA) A said: - He/She had been at this facility for two and a half years and residents do not get snacks passed to them on a consistent basis and had no idea why; - He/She had heard residents complain about the food portion sizes, that there is no seasoning, and the residents say it looks like slop. He/She feels it doesn't look very appealing; - Condiments are not passed on trays. It just doesn't happen, no salt, no pepper, no sugar; During an interview on 07/24/2025 at 09:00 A.M., ADON B said: -Residents should get snacks twice a day delivered by CNA's, nurses, CMT's and sometimes the residents come up and ask for a snack; - Dietary brings a tray of snacks two to three times a day so staff have them to offer; - He/She had heard the residents complain about the food. Sometimes they complain about too small of portions or don't like what's on the menu; - Condiments should be passed on the trays and the carts have cubbies on them with the extra condiments; -There is an always available menu and substitutions are offered; - He/She believes residents get seconds upon request, but staff will try to serve everyone first then accommodate those who want more food. During an interview on 07/24/2025 at 10:02 A.M., CNA B said: -The staff will put the snacks at the nurses station and the ones who can, get to take for themselves; - He/She had heard residents complain that no one brings them snacks; - He/She had residents complain about the food all the time being cold, not enough food or little servings. Also resident's don't get what was ordered; - He/She said condiments are not passed with room trays; - Substitutions choices are not always provided to the resident's; During an interview on 07/24/25 at 02:30 P.M., the Administrator said: - The residents should get snacks passed to them in the morning, noon and night; - He/She had heard the residents complain about the food and it is an ongoing issue; - Residents are encouraged to eat in the dining room, so they don't have to wait for hall trays; - Condiments are at the nurse's station and in the food carts; - CNA's are responsible for passing the condiments and should get residents what they need when they are passing room trays; - Residents can get food substitutions when they ask; - If a resident wants seconds, they should tell the CNA who will go to the kitchen to get the meal as soon as it is available. 5. Review of Resident #33's Quarterly Minimum Data Set (MDS), dated [DATE], showed:- Resident had moderately impaired cognition;- Resident was independent in eating;- Diagnosis: coronary artery disease Observation of Resident's room on 7/22/25, showed:- 9:32 A.M. breakfast delivered to Resident's room;- 9:33 A.M. Resident turned on call light, CNA (G) answered call light and told resident he/she would leave the call light on until someone brought him/her some coffee for breakfast. He/she was currently passing out meal hall trays and would tell another staff member to get the coffee for the resident; During an interview on 7/22/25 at 9:41 A.M., the resident said:- He/she did not get coffee with his/her breakfast meal though he/she has told staff he/she would like coffee each day with breakfast and lunch;- Staff do not check with him/her in the evening to see what he/she wants for breakfast the next day;- Staff have told him/her in the past there is no coffee available for breakfast;- Coffee is very important to the resident and when he/she constantly does not get it with their meal, it frustrates him/her; Observation of Resident's breakfast meal ticket on 7/22/25 at 9:45 A.M, showed:- No annotation of what the resident wanted to drink for breakfast, or any choices indicated by the resident. Breakfast slip was a print out of all the food menu choices for breakfast on 7/22/25; During an interview on 7/22/25 at 9:50 A.M., CNA (E) said:- Dietary staff normally take resident room orders the night before breakfast and turn them into dietary department;- Resident normally requests coffee for breakfast and lunch each day; During an interview on 7/23/25 at 10:22 A.M., the resident said:- Dietary staff came by last night and asked him/her what they wanted for breakfast and he/she asked for coffee with meals; Observation on 7/23/25 at 10:24 A.M., showed:- Meal ticket for resident did not have coffee written down as a menu choice; 6. Review of Resident #55's Annual MDS, dated [DATE], showed:- Resident is moderately cognitively impaired;- Resident is independent for eating;- Diagnosis: coronary artery disease, peripheral vascular disease, kidney disease, respiratory failure, and diabetes; During an interview on 7/22/25 at 9:15 A.M., the resident's family member said:- Resident ordered cereal and milk for breakfast but did not receive it this morning. This is a normal daily request from the resident since he/she has strict cultural dietary restrictions. Is it very frustrating for the resident when he/she does not get simple menu requests that the facility can fill; Observation on 7/22/25 at 9:18 A.M., showed:- Resident's meal ticket did not have cereal with milk on it as a menu choice; During an interview on 7/22/25 at 9:30 A.M., ADON (B) said:- Dietary staff will get resident orders the day before breakfast, so morning dietary staff can prepare the meal according as to what the resident has requested; During an interview on 7/22/25 at 9:35 A.M., CNA (G) said:- Cereal with milk is a standard menu choice for the Resident and he/she was not sure why it was not on their tray this morning; 7. Review of Resident 8's Quarterly MDS, dated [DATE], showed:- Resident is moderately cognitively impaired;- Resident requires supervision from staff for eating;- Diagnosis: cancer, kidney disease, and malnutrition; An observation on 7/24/25 at 10:30 A.M., showed the resident received a breakfast hall tray from staff; During an interview on 7/24/25 at 10:52 A.M., the resident said:- He/she ate breakfast that morning at about 10:30 A.M. but would prefer to eat at 8:00 A.M. and still have the choice to eat in his/her room;- It is not enjoyable to eat breakfast this late and so close to lunch time; 8. Review of Resident #11's Quarterly MDS, dated [DATE], showed:- Resident is cognitively intact;- Resident is independent for eating;- Diagnosis: anemia, peripheral vascular disease, kidney disease, respiratory failure, and diabetes; During an interview on 7/24/25 at 12:22 P.M., the resident said:- He/she likes soup, but it's not listed on the menu ticket and you have to ask staff what the soup is or you don't know what they are serving that day since it changes all the time; Observation of Dietary Aide (C) on 7/24/25 at 12:25, showed:- Staff member taking orders from residents but not telling the residents what soup was available today; During an interview on 7/24/25 at 12:28, Dietary Aide (C) said:- Today's soup is broccoli cheese and it is written on the posted menu;- He/she does not tell each resident what today's soup is from the kitchen, they would have to ask him/her or they can put down on the meal ticket they want the soup of the day. Chicken noodle is always available; Observation on 7/24/25 at 12:30, showed:- No menus posted in the facility that showed what today's soup was for the residents;- Meal tickets did not list any soup or that broccoli cheese was an available choice for residents;- No meal times are posted anywhere in the facility; During an observation of the dining room on 7/22/25 at 7:31 A.M., showed:- The facility has two dining rooms with a partition wall separating the middle of each dining room from each other;- Both dining rooms look identical except the main dining room tables have condiments holders with various choices for the residents to choose from during their meal. The alternate dining room has no condiment holders and only a few tables with some salt and pepper shakers on them for the residents; During an interview on 7/22/25 at 8:13 A.M., Dietary [NAME] (A) said:- Breakfast starts at 8:30 A.M. for the residents then hall trays are worked on and sent to the residents; During an interview on 7/22/25 at 8:40 A.M., LPN (A) said:- Both dining rooms are the same and are set up identical, but staff tries to put the assisted diners in the alternate dining room for efficiency of service to the residents that need dining help. Anyone can chose to eat in the alternate dining room; Observation on 7/24/25 at 10:19 A.M., showed:- Breakfast hall trays passed to resident rooms on the 160 Hallway; Record Review of Dining Service Mealtimes, undated, showed:- Breakfast 8:00 A.M., Lunch 12:00 P.M., Dinner 5:00 P.M.;- Dining service times are planned in accordance with resident preferences and staffing available at mealtimes; During an interview on 7/24/25 at 1:30 P.M., the Administrator said:- Breakfast is at 8:00 A.M, Lunch 12:00 P.M., and Dinner 5:00 P.M.;- She would expect soup to be listed if it's a main course and staff should inform residents of what the soup of the day is for the meal;- She would expect mealtimes to be posted and the menu updated daily;- She would expect dietary staff to take breakfast orders the day befor for the breakfast meal;- She would expect both dining rooms to be set up exactly the same for residents;

Based on observation, interview and record review, the facility failed to maintain an effective pest control program when numerous flying insects were observed by three residents (Resident #60, #71, and #76) throughout the facility. This affected three of 19 residents sampled. Facility census was 95. Request for facility Pest Policy not provided; Record review of facility pest service, showed:- 7/11/25 Vendor observed fly activity around dumpsters and applied fly treatment. Food residue on equipment and food filth on walls and drains under dish machine, interior door left open;- 6/10/25 Vendor observed fly activity around dumpsters and applied fly treatment. Food residue on equipment and food filth on walls and drains under dish machine, interior door left open; 1. Review of Resident #71's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 06/24/25, showed:-Cognitive skills intact;- Diagnoses included: Hemiplegia (condition characterized by the paralysis of one side of the body, affecting the arm, leg, and sometimes the face), diabetes, and high blood pressure; During an interview on 7/24/25 at 11:10 A.M., the Resident said:- The gnats are terrible in the dining room and they are everywhere in the facility. They try to get into the food and they disgust me. Resident had only one hand and it's for holding silverware while eating so it's impossible to bat them away from his/her food.- The situation doesn't feel sanitary, and they are annoying to hear in your ears. Resident had heard visitors complain about them as well. The gnats are his/her room and had told staff but the staff say nothing can be done about it; Observation on the 100 Hall on 7/21/25 at 10:05 A.M., showed:- Frequent flying gnats in the hallway area; Observation in dining room on 7/22/25 at 7:33 A.M., showed:- Open trash can at drink station attracting flying pests;- Many gnats and flying insects in the area of the drink station; Observation in kitchen on 7/22/25 at 9:50 A.M., showed:- Trash can overflowing at handwashing station;- Multiple drains dirty with food debris and trash; Observation of the outside trash disposal area on 7/22/25 at 10:40 A.M., showed:- Trash dumpster lids not closed and heavy concentration of flies and gnats in the area; During an interview on 7/24/25 at 9:10 A.M., the Maintenance Supervisor said:- The facility has been using an outside vendor to handle pest control which consisted of guidance provided to the facility for prevention along with spraying conducted by the vendor;- Main causes are dirty drains that contain food in the kitchen and dining room area;- It's normally a seasonal outbreak with gnats during the summer months, by fall and winter they go away; Observation on the 160 Hall on 7/24/25 at 10:36 A.M., showed:- Gnats observed in the hall; 2.Review of Resident #60's Quarterly MDS, dated [DATE], showed:-Cognitive skills intact.- Independent with eating.- Moderate assistance required by facility staff with transfers and showers.- Diagnoses included: Renal failure (condition where the kidneys lose the ability to adequately filter waste and excess fluids from the blood) requiring Hemodialysis (medical procedure that filters a person's blood to remove waste products and excess fluid when the kidneys are unable to do so), Diabetes, and High Blood Pressure. Review of the Comprehensive Care Plan, dated 04/28/25, showed:-Congestive heart failure diagnosis and nursing staff are required to encourage adequate nutrition and offer small frequent feedings.- Potential/actual nutritional problem related to renal failure/dialysis and nursing staff are required to provide and serve diet as ordered and monitor, record, report signs or symptoms of malnutrition to provider.- At risk for low blood pressure and nursing staff are required to encourage adequate fluid intake and a healthy diet. During an interview on 07/24/2025 at 08:00 A.M., the Resident said he/she sees gnats and spiders sometimes and we can't have that, we're too old and don't want to get bit. 3.Review of Resident #76's Quarterly MDS, dated [DATE], showed:-Cognitive skills intact.- Setup or clean up assistance required by staff for eating.- Substantial assistance required by staff for transfers and mobility.- Diagnoses included: High blood pressure, osteoarthritis, and depression. Review of the Comprehensive Care Plan, dated 04/30/25, showed:-Potential nutrition/hydration risk related to diagnoses and nursing staff are required to provide and serve diet as ordered and monitor, record, and report signs and symptoms of malnutrition to provider.- Potential impairment to skin integrity related to impaired mobility and incontinence and staff are required to encourage good nutrition and hydration to promote healthier skin.- Had pain related to osteoarthritis and staff are required to monitor, record, and report to nurse loss of appetite, refusal to eat, and weight loss. During an interview on 07/24/2025 at 08:00 A.M., the Resident said:-He/She saw gnats flying in the hallway and a spider in the bathroom.-It makes him/her feel scared and doesn't want to get bit. During an interview on 07/24/2025 at 08:55 A.M., Certified Nursing Assistant (CNA) A said the gnats are bad in the facility. During an interview on 7/24/25 at 1:30 P.M., the Administrator said the Maintenance Supervisor is working with an outside vendor for pest control. She didn't notice any gnats or fruit flies last week and she believed if there was an increase in gnats it's due to the weather;

Based on interview and record review, the facility failed to provide personal funds and a final accounting within thirty days upon discharge for two residents (#111, #112). This affected two of 19 residents sampled. Facility census was 95. Request for a policy covering resident funds upon discharge was not provided by the facility;1. Review of the facility's interim aging report, dated [DATE], showed the following residents had money in the facility's operating account:-Resident #111 discharged on [DATE], with a credit balance of $2,641.41 in the Resident Liability account;-Resident #112 discharged on [DATE], with a credit balance of $1,360.00 in the Private Pay account;During an interview on [DATE] at 10:30 A.M., the Business Office Manager (BOM) said:- Resident #111's account is being held up for refund due to money owed to Medicare;- At this time the BOM was not able to provide any documentation or correspondence with Medicare that this issue with Resident #111 had been addressed;- Resident #112 was due a refund but it had not processed yet and due to switching vendors the refund had been delayed;- The normal expected process time for providing refunds to discharged or deceased resident accounts was 30 days;During an interview on [DATE] at 1:30 P.M., the Administrator said:- Refunds should be provided within 30 days for deceased and discharged residents when required;

Based on observations, interviews, and record review, the facility failed to ensure staff treated residents in a manner to maintain their dignity when staff failed to knock on a resident's door and wait for a response before entering which affected one of the 19 sampled residents, (Resident #57), and when staff stood to assist Resident #29 to eat. The facility census was 95. Review of the facility's policy for Resident Rights, dated 12/2024 showed:- Each resident residing in this community has the right and will be afforded the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the community without interference, coercion, discrimination or reprisal;- No staff member or contracted provider of care will hamper, compel, treat differently or retaliate against a resident for exercising Resident Rights;- Each resident will have autonomy and choice, to the maximum extent possible, about how each resident wish to live his/her everyday life and receipt of care, subject to the community's policies and procedures as long as those policies do not violate any requirement;- Resident rights include but are not limited to: exercise his/her rights; privacy and confidentiality. 1. Review of Resident #57's care plan, revised 5/27/25 showed:- The resident had an activities of daily living (ADL) self care performance deficit. The resident had urinary incontinence, wears incontinent briefs for dignity, and able to change briefs with minimal assistance. The resident required the assistance of one staff with dressing. Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/30/25 showed:- Cognitive skills moderately impaired;- Independent with toilet use, dressing and transfers;- Occasionally incontinent of urine;- Diagnoses include high blood pressure, anxiety and depression. Observation and interview on 7/22/25 at 8:31 A.M., showed:- Housekeeping Staff A opened the resident's closed door and entered the resident's room and did not knock or announce him/herself;- He/She spoke very little English and did not understand when asked if he/she was supposed to knock on the resident's door before he/she opened it;- The resident said he/she would prefer for the staff to knock and announce themselves before the staff entered his/her room. Observation and interview on 7/22/25 at 8:36 A.M., showed:- An unknown Certified Nurse Aide (CNA) did not knock and opened the resident's door and said he/she was looking for the mechanical lift. Observation on 7/22/25 at 8:37 A.M., showed:- An unknown housekeeper did not knock on the resident's door and entered the room. He/She cleaned the resident's bathroom then left the room. During an interview on 7/24/25 at 8:49 A.M., Licensed Practical Nurse (LPN) B said:- The staff should knock on the resident's door and announce themselves before they entered the resident's room. During an interview on 7/24/25 at 9:33 A.M., CNA A said:- Staff should knock and announce themselves before they opened the resident's door. During an interview on 7/24/25 at 10:12 A.M., CNA E said:- Staff should knock on the resident's door before they entered the room. During an interview on 7/24/25 at 11:19 A.M., the Director of Nursing (DON) said:- The Staff should knock and announce themselves before they entered the resident's room. 2. Review of Resident #29's Quarterly MDS, dated [DATE], showed:- Resident had severe cognitive impairment;- Resident was dependent on staff for eating assistance;- Diagnosis: stroke, cancer, anemia, diabetes, and multiple sclerosis; Observation on 7/21/25 at 12:41 P.M., showed:- LPN (A) standing over the resident for four minutes while feeding resident food with a spoon and helping resident to drink out of a cup; During an interview on 7/24/25 at 8:40 A.M., LPN (A) said:- For residents that require assistance from staff to eat, ideally a staff member would sit between no more than two residents to help each one during the meal. Staff should be sitting and not standing when helping residents to eat.

Based on interview and record review, the facility failed to check the Nurse Assistant (NA) registry prior to employment to ensure all newly hired employees did not have a Federal Indicator (marker given to individuals who have committed abuse/neglect for four out of the 10 sampled employees and failed to check the Family Care Safety Registry (FCSR) prior to employment to ensure all newly hired employees did not have negative records/backgrounds for two out of 10 sampled employees hired since October 2024. The facility census was 95.Review of the facility's abuse policy, revised on 1/2024 showed- Each resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone, including staff, volunteers, and other residents. All employees will have a criminal and state/federal required criminal background checks completed prior to start of employment. 1. Review of personnel records for the following staff hired since October 2024, showed:- Certified Nursing Assistant (CNA) C hired 03/17/25, NA registry check 04/03/25;- CNA D hired 02/17/25, NA registry check not dated;- CNA E hired 03/10/25, NA registry check 04/23/25;- Dietary Server A hired 06/30/25, NA registry check 07/03/25;- CNA F hired 12/09/24, NA registry check 04/14/25. 2. Review of personnel records for the following staff hired since October 2024, showed:- Dietary Aide A hired 10/04/24, no FCSR letter;- Dietary Aide B hired 10/01/24, no FCSR letter. 3. Review of Performance Improvement Plan (PIP): Employee Background Checks, dated 03/31/25, showed:- Identified Performance Issues: *Employees not having printed letter from FCSR in their employee file; *Date not on all employees' CNA registry printout in their employee file; *Employees do not have reference checks completed;- Identification of the resident(s) found to have been affected by the deficient practice includes: *All residents have the potential to be affected;- Systems/Action taken to resolve Identified Performance Issue: *All current employees' files were audited for FCSR letter, dated CNA registry printout, and reference checks; *Administrator will audit four new hires weekly for 4 weeks to ensure that the FCSR letter, a dated CNA registry printout, and reference checks are in their file. During an interview on 07/24/2025 at 12:13 P.M., Payroll/HR said:- He/She began working at the facility three to four months ago and wasn't sure what had gone wrong with this process;- He/She now gets the employee paperwork and starts the background checks immediately;- The Administrator audits the employee paperwork after the employee had completed orientation and is onboarded and then he/she reviews and signs the packet. During an interview on 07/24/25 at 02:00 P.M., the Administrator said he/she had no as to explain why the paperwork couldn't be produced to show the background reports were completed and that all new employees should have completed background checks done prior to employment.

Based on observation, interview, and record review the facility failed to establish and maintain an infection and control program designed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable disease and infections when the facility failed to ensure that staff used proper Enhanced Barrier Precautions (EBP) while providing cares for two of the 19 sampled residents (Resident #2 and # 10) and failed to ensure that new staff had completed a Tuberculin (TB) skin test prior to working. The facility census was 95.Review of the facility policy Infection and Prevention and Control Program (IPCP), dated 2019, showed: - It is the policy that this facility's IPCP is based upon information from the Facility Assessment and follows national standards and guidelines to prevent, recognize, and control the onset and spread of infection whenever possible. The IPCP includes: A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services; Standard and transmission-based precautions to be followed to prevent the spread of infections with selection and use of personal protective equipment (PPE); TB screening of staff; and establishes facility-wide systems for the prevention, identification, investigation, and control of infections of residents, staff, and visitors. It must include an ongoing system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility and procedures for reporting possible incidents of communicable disease or infections. Review of the facility's undated policy for Enhanced Barrier Precautions showed:- Enhanced Barrier Precaution (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. EBP involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk for MDRO acquisition (such as residents that have wounds or indwelling medical devices). This is because devices and wounds are risk factors that place these residents at higher risk for carrying or acquiring a MDRO and residents colonized with a MDRO are asymptomatic or not presently known to be colonized.- EBP expand the use of gown and gloves beyond anticipated blood and body fluid exposures. They focus on use of gown and gloves during high contact resident care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. EBP are recommended for residents known to be colonized or infected with a MDRO, as well as those at increased risk of MDRO acquisition. Standard Precautions still apply while using EBP. - Enhanced Barrier Precautions are recommended for residents with any of the following: infection or colonization with an MDRO or a wound or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO. Indwelling medical devices include central venous catheters, urinary catheters, feeding tubes, tracheostomies/ventilators. - High-contact resident care activities where a gown and gloves should be used include changing briefs or assisting with toileting, providing hygiene, or transferring residents form one position to another. 1. Review of Resident #10's undated care plan, showed:- The resident had a pressure ulcer to his/her coccyx and was a Stage 3 (a full thickness of skin is lost, exposing the subcutaneous tissues; presents as a deep crater with or without undermining adjacent tissue). Administer treatments as ordered and monitor for effectiveness. Encourage good nutrition and hydration to promote healthier skin. Monitor pressure areas for changes in color, sensation, temperature and report any change to the nurse. Review of the resident's Quarterly MDS, dated [DATE] showed:- Cognitive skills severely impaired.- Lower extremities impaired on both sides.- Dependent on the assistance of staff for toilet use, dressing, and transfers.- Always incontinent of urine.- Occasionally incontinent of bowel.- Had one Stage 3 pressure ulcer.- Diagnoses included dementia, weakness and pressure ulcer. Observation on 7/23/25 at 7:31 A.M., showed:- CNA E entered the resident's room, sanitized his/her hands and applied gloves;- CNA E provided incontinent care to the resident;- The resident had an opened wound on his/her coccyx and did not have a dressing covering it;- CNA E dressed the resident for the day;- CNA E did not wear a gown or mask when he/she provided incontinent care. During an interview on 7/24/25 at 10:12 A.M., CNA E said:- He/She should have worn a gown and a mask when he/she provided incontinent care to the resident. During an interview on 7/24/25 at 11:19 A.M., the DON said:- The staff should wear a gown and gloves when a resident has a wound and is on EBP. 2. Review of Resident #8's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 07/01/2025, showed:-Cognition intact;-Diagnoses: Stroke, Amputation, Hip and knee replacement, Renal Failure. Review of the Care Plan dated 7/18/25 showed: -Requires hemodialysis using left upper extremity fistula graft (an access port for dialysis);-Do not draw blood or take blood pressure in the arm with the graft;-Monitor document and report to the doctor any bleeding, hemorrhaging, bacteremia, or septic shock;-Monitor a bruit (sound heard over the fistula graft) and a thrill (a rhythmic feeling over the fistula graft);-Notify nephrologist immediately if there is no thrill, no pulse or vibration in the graft, pus draining from the catheter, fistula or graft, redness or swelling in the accessed arm, coldness, numbness, aching or weakness of the access arm. Observation of Resident #8 on 7/21/25 at 1:00 P.M., showed:-Left upper arm without redness or drainage;-No barrier precautions or equipment at entrance to room or inside the room. During an interview on 7/22/25 at 0900 A.M., Resident #108 said;-there are no problems with my arm where they do dialysis;-Staff have not worn a gown when in my room. 3. Review of Resident #108's Face Sheet showed:-Acute renal failure and lung disease;-Repeated falls;-Dependent upon renal dialysis. Review of the Care Plan dated 7/16/2025, showed:-The resident is on enhanced barrier precautions due to a right chest catheter for dialysis;-The resident needs hemodialysis using the right chest catheter;-Do not draw blood or take blood pressure in his/her arm with the graft;-The resident receives dialysis on Monday, Wednesday, and Friday;-Monitor for redness or swelling in the accessed arm;-Monitor pulse, vibration or a thrill in the fistula or graft for arteriovenous grafts only. Observation of resident #108 on 7/21/2025 at 2:00 P.M., showed;-No barrier precautions inside or outside of room;-Dressing clean, dry, and intact to right chest catheter. During an interview with Resident #108 on 7/21/25 at 2:00 P.M., she/he said:-He/she is new to dialysis but it went okay;-He/she does not believe staff wear gowns when in room. 4. Review of Resident #28's Face Sheet showed:-Right sided paralysis of body;-Parkinson's disease;-Suprapubic catheter to assist with urination. Review of the Care plan dated 5/29/25 showed:-Catheter care every shift and as needed;-Position catheter bag and tubing below the level of the bladder and ensure privacy bag is in place;-check tubing for kinks every shift and when repositioned;-report any signs and symptoms of infection to physician. Observation of Resident #28 on 7/21/25 at 2:00 P.M., showed:-No barrier precautions or equipment at entrance to room or inside the room. During an interview on 7/23/25 at 11:00 A.M., CNA C said:-An isolation gown, gloves and mask are indicated used if the resident is on enhanced barrier precautions; During an interview on 7/23/25 at 1:30 P.M., the DON said residents should have a gown, gloves, and mask on when caring for residents on enhanced barrier precautions. 5. Review of Resident #2's Quarterly MDS, dated , 5/30/25, showed:- Resident is cognitively impaired;- Resident requires moderate assistance from staff for oral hygiene, personal hygiene, and upper body dressing;- Resident requires maximum assistance from staff for lower body dressing;- Resident was dependent on staff assistance for toileting hygiene and showering;- Diagnoses: non-traumatic brain injury, coronary artery disease, obstructive uropathy (urine flow is blocked in the urinary tract), viral hepatitis, and Alzheimer's Disease; Review of Resident's Care Plan, revised 5/27/25, showed:- Resident had a suprapubic catheter related to obstructive uropathy and is at risk for complications;- Resident was on enhanced barrier precautions due to supra pubic catheter. Staff are to wear gown and gloves when performing high-contact resident care activities; Observation on 7/23/25 at 8:02 A.M., showed:- Resident's room was marked as requiring enhanced barrier protection and required staff to wash hands before entering the room and when performing cares for the resident, staff are to wear a gown and gloves;- CNA (G) wiping and cleaning resident's face with a washcloth, inserting dentures into the resident's mouth, and adjusting resident's clothes so they fit properly. CNA (G) was wearing gloves only with no isolation gown on; During an interview on 7/23/25 at 8:08 A.M., CNA (G) said:- He/she only needed to wear a gown when cleaning the resident's catheter area; During an interview on 7/24/25 at 1:30 P.M., the DON said:- Staff performing cleaning and wiping of a resident's head and face are required to wear a gown and gloves if the resident is under enhanced barrier precautions. This also includes when adjusting their clothes and putting dentures into their mouth; 6.Review of the facility policy Infection Prevention and Control, Tuberculosis Screening - Employees, dated 2019, showed: Residents of long-term care facilities have been identified as a high-risk group for re-activation of latent TB infection and potential spread of TB within the facility. This facility has a comprehensive TB screening program; It is the policy of this facility to assess risks for tuberculosis based on regional/community data and screen staff according to state law; All healthcare workers will be tested for tuberculosis upon hire and yearly thereafter. Initial testing will be a two-step procedure with the first dose given before beginning work and the second booster dose to be given 7-21 days after the first dose; New employees will not be allowed to work until the Tuberculin Skin Test (TST), or chest x-ray results are known; Employees who will be receiving the two-step TST may begin work after the first step results are negative. During an employee record review of hired employees, since October 2024, a random sampling of 10 employees was selected and reviewed on 07/23/25 and showed: seven employees did not have documentation in their employee record to show that a TB skin test had ever been completed. During an interview on 07/24/2025 at 12:13 P.M., the Payroll/HR manager said: He/She started 3-4 months ago and was not sure why the TB skin test hadn't been done prior but when new staff starts pre-employment screening, the first TB test is given and paperwork is completed and asks the employee to return in 72 hours for the skin test to be read. The Director of Nursing (DON) then gets the paperwork after first TB test and handles it from there ensuring the second TB is completed. Finally, the Administrator audits the paperwork after the employee has completed orientation and is on-boarded and signs the packet as completed. During an interview on 07/24/25 at 02:30 P.M., the Administrator said the facility was not in compliance and all new employees should be screened with a TB skin test.

Based on observation, record review, and interview, the facility failed to develop and implement a comprehensive person-centered care plan for one of 19 sampled residents (Residents #69) by not addressing incontinence care with person-specific goals, measurable objectives, and time frames in order to evaluate the resident's progress towards obtaining his/her goals. The facility census was 95. Review of the facility's Care Planning policy, dated 12/2024, showed:- Every resident will be assessed using the Minimum Data Set (MDS) according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual;- Upon completion of comprehensive assessments, CAAs will be triggered to flag areas of concern that may need to be addressed in the care plan for the resident;1. Review of the Resident #69's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 7/22/25., showed:- Cognition is impaired;- Limited range of motion on one side of his/her upper and lower extremity;- Resident required staff supervision for eating;- Resident required moderate staff assistance for oral hygiene, personal hygiene and dressing;- Resident was dependent on staff assistance for toileting hygiene and showering;- Resident used a wheelchair for mobility;- Resident was always incontinent of bowel and bladder;- Diagnosis: stroke and kidney disease;Review of Resident's Care Plan, revised 5/5/25, showed:- Resident had activities of daily living (ADLs) performance deficit and required two-person assistance by staff for toileting;- No staff interventions in the Care Plan related to resident incontinence or catheter usage;Review of the Resident's Progress notes for May-July 2025, showed:- 5/26/25 Daily Skilled Nurse's Note: Resident was incontinent of bladder, was not on a toileting program for bladder incontinence, does have a urinary catheter, and used no items to assist with bladder control;- 5/25/25 Daily Skilled Nurse's Note: Resident used pads/briefs to assist with bladder control;- 5/19/25 Daily Skilled Nurse's Note: Resident was incontinent of bowel and was not on a toileting program for bowel incontinence;-5/18/25 Daily Skilled Nurses Note: Resident was incontinent of bladder, was not on a toileting program for bladder incontinence, does have a urinary catheter and used bladder control briefs;5/15/25 Daily Skilled Nurses Note: Resident was incontinent of bladder, was not on a toileting program for bladder incontinence and does not have a urinary catheter. Resident used briefs/toilet to assist with bladder control;- Review of Daily Skilled Nurses Notes contained inconsistencies with regards to catheter usage and interventions that resident was using for bladder control;During an interview on 7/21/25 at 3:05 P.M., the resident said:- He/she had been incontinent since arriving to the facility. Resident would like the facility to work on a solution so they he/she would not keep soiling themselves. The resident said he/she feels very dirty each time it happens and it doesn't feel good at all;During an interview on 7/23/25 at 10:05 A.M., the DON said:- If a resident is considered incontinent per the MDS screening then that information and planning goes directly into the Care Plan for the resident. A specific plan would be developed and entered into the Care Plan for the staff to execute;- Any interventions for the resident regarding incontinence would be seen in the progress notes as they are implemented;During an interview on 7/24/25 at 8:15 A.M., CNA (G) said:- The resident is a two person assist with mobility transfers and the resident had good and bad days with incontinence. He/she was not familiar with any specific interventions for the resident. - There had been no improvement in the resident's incontinence; During an interview on 7/24/25 at 8:32 A.M., RN (A) said:- The resident isn't on a toileting program;- The main intervention with this resident is to toilet him/her before meals which helps in planning for when he/she might have to go;- He/she would expect incontinence to be care planned for a resident;- If the resident had more mobility then incontinence would not be an issue, physical therapy could be of assistance in this case;During an interview on 7/24/25 at 9:20 A.M., MDS Coordinator (A) said:- After the MDS is completed for a resident multiple departments get together to work out a care plan based on information gathered. At this point, the team would enter incontinence interventions and goals for a resident;- The reason to care plan incontinence is to prevent skin breakdown, improve bladder function and avoid adverse effects to the resident. There should be goals documented and measures stated for each resident's plan;During an interview on 7/24/25 at 1:30 P.M., the DON said:- She would expect incontinence to be identified in the MDS and to be care planned for each resident;- Care planning incontinence, provides for skin integrity care and care for the resident;

Based on observations, interviews, and facility policy review, the facility failed to store foods in sealed containers in the freezer, ensure the cleanliness of the ice machine, and use adequate hand hygiene during food service in one of one kitchen. These failures had the potential to cause the spread of foodborne illness to all 96 residents. Findings include: Review of the facility's undated policy titled, Kitchen Sanitation provided by the facility, revealed Guideline: To ensure that food prepared in the facility is done so in a safe and sanitary manner. Procedure: The Food Service Manager will monitor food safety and sanitation of the Dietary Department on a daily basis .The Food Service Manager will develop a cleaning schedule for the department and is responsible for its completion .The Food Service Manager will provide written cleaning instructions for each area and piece of equipment in the kitchen. The instructions specify which chemical should be used for each task. During initial observations of the kitchen on 06/25/24 at 9:07 AM, the following were observed: -In the ice machine, a brownish-yellowish-greenish substance was on the inside of the lid. During a concurrent interview, the Dietary Manager (DM) stated the maintenance department was responsible for cleaning the ice machine and had done it recently. -In the stand-alone freezer, there were bags that were open and unsealed containing chicken nuggets, hash brown patties, and hamburger patties. During a concurrent interview with the DM, she stated foods should never be open and unsealed in the freezer. The DM confirmed the chicken nuggets, hash brown patties, and hamburger patties were open and unsealed. She removed the observed items and discarded them. The DM stated she was new to the position and had been focusing on cleaning up the walk-in refrigerator and freezer and had not noticed the open and unsealed items in the stand-alone freezer. During observation of lunch service on 06/27/24 from 11:40 AM to 1:00 PM in the kitchen, the following were observed: -At 11:40 AM, the ice machine was again observed with a yellowish-greenish-brownish substance inside the lid. The plate device was observed with crumbs on the outside. -At 12:03 PM, a breadstick fell from a pan onto the top of the steam table. Dietary cook (DC) 2 put the breadstick back in the pan to be served. -At 12:14 PM, DC2 began to serve meals from the steam table. She donned gloves, then opened the plate warming device and grabbed several plate warmers and plates with her gloved hands. Then, she began plating squares of lasagna using a spatula in one hand, and the other hand in the same glove to slide the lasagna off the spatula. -Throughout lunch service, DC used her gloved hands to open the plate warming device and remove the plate warmers, touched carts holding meal trays, touched oven handles, and donned oven mitts over the gloves, then used the same gloves to pick up breadsticks or pieces of bread for plating. -At 12:32 PM, a meal tray card that had been handled and written on in pen dropped into the pan of breadsticks. DC1 removed the meal tray card using her gloved hands and continued to serve the breadsticks that touched the meal tray card. -At 12:33 PM, DC1 used the same gloved hands to pick up a piece of bread out of the bag for serving. During an interview on 06/28/24 at 2:34 PM, the DM stated she had noticed DC1 and DC2 were using unsanitary gloves to pick up bread and breadsticks during lunch service on 06/27/24. She stated she even tried to correct the staff during service to no avail. The DM stated she expected the cooks to use tongs or utensils to serve all foods and should never touch ready-to-eat foods, even with gloves on, because gloves could become contaminated. The DM also confirmed there was a yellowish-brownish-greenish substance on the inside of the ice machine on the lid. She stated she had not noticed it because she was focused on the ice compartment below. The DM stated the maintenance department had just cleaned the ice machine the week before. During an interview on 06/28/24 at 2:45 PM, the Maintenance Director (MD) stated he cleaned the ice machine monthly and just cleaned it last week. He stated, however, that he did not notice the substance on the inside of the lid, as he was focused more on the ice compartment below. He stated the cleaning involved the entire machine, including removing the ice and changing the filter.

Based on observations, interviews, record review, and facility policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) for three of four residents (Resident (R) 247, R14, and R2) reviewed for implementation of EBP with chronic wounds or indwelling devices (intravenous (IV) line, enteral feeding tubes, urinary catheter, or central venous catheter) who were candidates for EBP of 25 sample residents. These failures created the potential to spread multidrug-resistant organisms (MDROs) throughout the facility. Findings include: Review of the facility's undated policy titled, Infection Prevention and Control Manual-Enhanced Barrier Precautions provided by the facility, revealed Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk for MDRO acquisition (such as residents that have wounds or indwelling medical devices) .Enhanced Barrier Precautions are recommended for residents with any of the following: 1) Infection or colonization with a MDRO or 2) A wound or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO. Indwelling medical devices include central venous catheters, urinary catheters, feeding tubes, tracheostomies/ventilators. High-contact resident care activities where a gown and gloves should be used include: -Bathing/showering -Transferring residents from one position to another (for example, from bed to wheelchair) -Providing hygiene, -Changing bed linens, -Changing briefs or assisting with toileting, -Caring for or using an indwelling medical device, Performing wound care. 1. Review of R247's Admission Record located in the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses of esophageal obstruction and dysphagia. Since the resident was recently admitted , there was no completed Minimum Data Set (MDS) assessment for review. Review of R247's EMR under the Orders tab, revealed physician's orders, dated 06/13/24, for enteral feeding, enteral tube flushes, and medication administration via enteral feeding tube. Review of R247's Dietician Nutrition Assessment, dated 06/23/24 and located in the Assessment tab of the EMR, revealed She was having difficulty swallowing pta [prior to admission] to hospital and could only tolerate soft foods and liquids. She had a PEG [percutaneous endoscopic gastrostomy] placed and has been on enteral feeding. Review of R247's Care Plan, dated 06/13/24 and located in the Care Plan tab of the EMR, revealed The resident requires tube feeding - Dysphagia, Swallowing problem. During an observation on 06/28/24 at 8:50 AM outside of R247's room, the Hospice Registered Nurse (HRN) entered the room and approached the resident's bedside wearing only a mask. The HRN did not don (put on) a gown and gloves and began to provide care to the resident, including taking vitals and touching the resident's body. The HRN remained in R247's room until approximately 10:00 AM. During an interview on 06/28/24 at 10:08 AM, the HRN confirmed R247 used an enteral feeding tube and stated she had been providing hands-on care to R247, including applying topical medications and examining her. The HRN stated she had donned gloves while applying the topical medication but had not worn a gown during her encounter. The HRN stated the facility had not provided information to her regarding EBP, told her R247 should be on EBP, or asked her to wear a gown and gloves while providing high-contact care activities. During an observation of R247 in her room on 06/28/24 at 9:17 AM, Assistant Director of Nursing (ADON) 1 was training Licensed Practical Nurse (LPN) 4 on administering medications and tube feeding via gastrostomy tube (G-tube). LPN4 was assisting ADON1 during resident care. Both staff members performed hand hygiene and donned gloves. Neither staff member wore a gown during resident care. During an interview on 06/28/24 at 10:06 AM, LPN4 stated, Today is my first day here working. The Director of Nursing (DON) gave me verbal training on infection control, and I had to sign off on it this morning . I would have to double check with her if she trained me on EBP. I'm drawing a blank on what that is, but I will ask her and double confirm . I would not need a gown for foley but would do sterile technique. We don't use a gown right now and I'm under the impression that we don't need one for the g-tube . During an interview on 06/28/24 at 10:16 AM, LPN3 stated, I wear full PPE [personal protective equipment] when a resident has COVID, Clostridioides difficile (C-diff), (a bacterium that causes an infection of the colon, the longest part of the large intestine), the flu, or Methicillin-resistant Staphylococcus aureus (MRSA), (difficult-to-treat bacterial infection) in a wound . I wear a gown with g-tube or foley catheter if they are on known quarantine or have other infections going on. I don't wear a gown with normal catheter care or normal g-tube care. During an interview on 06/28/24 at 10:35 AM, LPN4 stated, I asked ADON1 about EBP. She said the protocols are not in place yet. However, they are going to start this week and implement them. During an interview on 06/28/24 at 12:36 PM, ADON1 stated, The protocol to gown up is not in place yet. We are going to start implementing them next week. During an interview on 06/28/24 at 2:19 PM, the Director of Nursing (DON) revealed that she was not aware that CMS [Centers for Medicare and Medicaid Services] had already implemented EBP. The DON stated the facility had purchased EBP signage and put together training materials to begin implementation in the facility next month, July. The DON stated there was currently no policy related to EBP for the facility. 2. Review of R14's Admission Record, located in the Profile tab of the EMR, revealed he was admitted to the facility on [DATE] with a diagnosis of neuromuscular dysfunction of the bladder. Review of R14's quarterly MDS located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 03/13/24, revealed he used an indwelling urinary catheter. Review of R14's EMR under the Orders tab, revealed a physician's order, dated 06/06/24, for use of an indwelling urinary catheter and catheter care. Review of R14's Care Plan, dated 01/24/24 and located in the Care Plan tab of the EMR, revealed, [R14] has a Suprapubic Catheter d/t [due to] Neurogenic Bladder. During an interview on 06/28/24 at 9:50 AM, Certified Nursing Assistant (CNA) 5 described how catheter care was completed. CNA5 stated the staff wore gloves while doing catheter care and then proceeded to list the correct steps in the care process. CNA5 verified the staff always wore gloves during catheter care, but confirmed the staff only put on masks, goggles, or gowns when the staff were aware of something in the resident's urine. During an observation on 06/28/24 at 10:12 AM in R14's room, the Restorative Aide (RA) and CNA4 entered the room to empty R14's catheter bag and provided catheter care. Both the RA and CNA4 donned gloves while providing care; however, neither staff donned a gown. Observation of R14's room entrance revealed no signage or indication that EBP was required, and no PPE supplies were available at the entrance. During an interview on 06/28/24 at 10:21 AM, the RA confirmed neither she nor CNA4 donned a gown while providing catheter care for R14. The RA stated she had been trained in EBP requirements; however, the facility had not yet implemented the use of EBP. During an interview on 06/28/24 at 10:51 AM, the DON stated the facility had not yet implemented EBP and was planning to do so in July. She stated she had already briefly educated the staff, had signs printed, and ordered mounted PPE holders to prepare for implementation of EBP, but staff had not yet implemented the use of EBP. 3. Review of R2's Admission Record located in the EMR under the Profile tab, revealed R2 was admitted to the facility on [DATE] with diagnoses that included neuromuscular dysfunction of the bladder. Review of R2's comprehensive Care Plan located in the EMR under the Care Plan tab, dated 04/05/21, revealed the following focus areas: suprapubic catheter. Interventions in place were to provide catheter care every day shift, change catheter PRN (as needed) for blockage or dislodgement, irrigate catheter as needed, check for kinks during care, monitor and report any pain, discomfort, or any signs of urinary tract infection (UTI). Further review revealed there were no EBP interventions. Review of R2's Physician's Orders, dated 06/05/24 and located in the EMR under the Orders tab, revealed orders as follows: Perform Indwelling Catheter Care (Suprapubic catheter wash catheter site with soap and water daily and flush catheter with 30 ml [milliliter] NS [normal saline] at bedtime. During an observation and interview on 06/25/24 11:31 AM, there was no EBP signage on the resident's door and no cart with PPE near or outside of the resident's room. An interview with R2 at this time revealed staff were not wearing gowns when performing catheter care. During an observation and interview on 06/28/24 at 11:37 AM, there was no EBP signage on R2's door and no cart with PPE near or outside of the resident's room. During an interview with the Infection Preventionist/Wound nurse (IP-WC) who was prepped to perform catheter care stated that staff only wore gloves when doing care. She stated that she had heard about EBP but that was not implemented in the facility, and she was aware there was a plan in place. But she was unaware that it became regulatory to have that in place two months ago. She verified there was no signage or PPE placed outside the resident's room. But agreed that any resident who had a chronic wound, indwelling medication device, or central line should have been on EBP. 40902 43353 46592

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure pressure ulcer treatment orders and pressure ulcer prevention measures were implemented for one of two residents (Resident (R) 3) reviewed for pressure ulcers of 25 sample residents. These failures had the potential to lead to wound deterioration or the development of avoidable pressure ulcers. Findings include: Review of the facility's policy titled, Pressure Ulcer/Pressure Injury Prevention (PUP/PIP) dated March 2022 and provided by the facility, revealed, A pressure ulcer/ injury (PU/PI) can occur wherever pressure has impaired circulation to the tissue. A facility must . implement, monitor, and modify interventions to attempt to stabilize, reduce, or remove underlying risk factors; and if a PU/PI is present, provide treatment to heal it and prevent the development of additional PU/Pl's [sic]. Review of R3's Admission Record, located in the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses including dementia, venous insufficiency, muscle weakness, and peripheral vascular disease. Review of R3's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/21/24 and located in the MDS tab of the EMR, revealed she was rarely/never able to understand others or make herself understood and staff assessed her with severely impaired cognition. She was at risk for the development of pressure ulcers but had no current pressure ulcer. She received a pressure-reducing device for her chair and bed. R3 required substantial to maximal assistance with bed mobility and moving from lying to sitting or sitting to lying. Review of R3's Care Plan, dated 06/05/24, revealed, [R3] has actual impairment to skin integrity r/t [related to] diagnosis of PVD [peripheral vascular disease], fragile skin to BLE [bilateral lower extremities], lymphedema. The approaches included, Float heels while in bed as tolerated .Follow orders for treatment of injuries .Administer treatments as ordered and monitor for effectiveness .[and] Monitor pressure areas for changes in color, sensation, temperature and report any change to nurse. 1. Review of R3's Skin Check Weekly & [and] PRN [as needed] assessments, located in the Assessments tab of the EMR, revealed: -On 05/17/24, there were no skin issues. -On 05/24/24, Open area noted to outer left foot measures 1.5 [centimeters (cm)] x [by] 1 [cm] x US [unstageable] with slough to center and peri wound intact. Treatment order obtained, care plan reviewed and update not needed. -On 05/31/24, there were no skin issues. -On 06/07/24, there were no skin issues. Review of R3's Health Status Note, written by Licensed Practical Nurse (LPN) 2, dated 05/24/24 and located in the Progress Notes tab of the EMR, revealed [R3] noted to have open area to outer left foot measures 1.5 [cm] x 1 [cm] and US with slough to wound bed and peri wound intact . New order noted - Cleanse area with wound cleanser, pat dry, apply nickel-thick Santyl, cover with calcium alginate [wound dressing] cut to fit, then border gauze. Change daily and PRN [as needed] if soiled. Order processed. Review of R3's May 2024 and June 2024 Treatment Administration Record (TAR) under the Orders tab of the EMR revealed a physician's order, dated 05/24/24, to Cleanse wound to outer left foot with wound cleanser, pat dry, apply nickel-thick Santyl [ointment used to promote healing] to wound bed, then calcium alginate cut to fit. Cover with border gauze. Change daily et [and] PRN if soiled. The order for the left outer foot wound was documented in the Unscheduled Other Orders section at the top of the page but did not show up in the scheduled orders to be provided. The TARs did not indicate the treatment had been performed for R3's left outer foot wound since it was ordered. Review of R3's Monthly Skin Check, dated 05/28/24 and located in the Assessments tab of the EMR, revealed the skin issue was a skin tear to the top of the left foot measuring 2cm long, 2cm wide, and 0.1cm deep. The assessment did not address the unstageable wound to the left outer foot. Review of R3's EMR revealed no additional documentation of the left outer foot wound, including measurements or assessments. Review of a hospice Progress Note, located in R3's paper hospice binder and dated 06/07/24, revealed, Patient's left foot wound is healed. During an interview on 06/27/24 at 2:02 PM, Licensed Practical Nurse (LPN) 2 stated R3's hospice nurse had notified of a wound to her left outer foot on 05/24/24. He stated the wound was superficial and looked like a blister that popped. LPN2 stated the wound was completely healed and the treatment should have been discontinued. LPN2 stated he did not know if the wound treatment order obtained on 05/24/24 was implemented, as it had been entered wrong into the EMR system and did not populate as a scheduled treatment order. He stated, It must have gotten done though since it's healed. During an observation on 06/27/24 at 2:15 PM in R3's room with the Certified Medical Technician (CMT), R3's left foot was observed with a dry, scabbed, and scarred circular area to the left outer foot below the pinky toe. The area was not open. During an interview on 06/28/24 at 1:30 PM, the Infection Preventionist/Wound Care Nurse (IP-WC) stated typically when a new wound was identified, she would complete a weekly wound assessment to describe the measurements, staging, and characteristics of the wound to monitor for progress. She stated, however, that she did not complete any assessments of R3's outer left foot wound as she messed up. The IP-WC stated she was unsure whether R3's wound care treatment order from 05/24/24 was implemented. During an interview on 06/28/24 at 2:07 PM, the Director of Nursing (DON) stated LPN2 did not enter the 05/24/24 treatment order in the EMR system correctly, so she could not see that the treatment had been done. She stated the LPN should have initiated a schedule to include the treatment order in the active TAR. 2. Review of R3's June 2024 TAR under the Orders tab revealed a physician's order, dated 09/20/22, for Heel protectors on when in bed as tolerated every day and night shift for Prevention. During an observation on 06/26/24 at 3:20 PM in R3's room, R3 was lying in bed wearing non-slip socks. Her heels were not floated, nor was she wearing heel protectors. R3's heels were in direct contact with the mattress. During an observation on 06/27/24 at 2:12 PM in R3's room, R3 was lying in bed with bare feet, directly in contact with the mattress. Her heels were not floated, nor was she wearing heel protectors. On 06/27/24, Certified Nursing Assistant (CNA) 4 and the CMT entered the room and verified R3 was not wearing heel protectors and her heels were not floated. The CMT stated R3 did not have any heel protectors (boots) and she had never been instructed to float R3's heels. CNA4 confirmed R3 did not have any heel protectors and she had not been instructed to float R3's heels. During an observation on 06/28/24 at 9:59 AM in R3's room, CNA4, CNA6, and the CMT assisted R3 in a transfer from her chair to her bed. The staff did not offer or attempt to apply heel protectors or float her heels. During an interview on 06/28/24 at 10:24 AM, LPN4 stated R3 had an order to use heel protectors as tolerated. LPN4 observed R3 in bed and verified her heels were not floated and she was not wearing heel protectors. He looked in the room and was unable to locate an extra pillow or heel protectors (boots). During an interview on 06/28/24 at 1:30 PM, the IP-WC stated R3 should have had boots (heel protectors) because she was at risk for skin breakdown to her feet. She stated she just did a sweep the other day to ensure all residents who needed them had boots. The IP-WC stated staff should have been applying heel protectors for R3 when in bed and she would have to do more staff education.

Based on record review, interview, and facility policy review, the facility failed to thoroughly investigate an allegation of verbal abuse for one of four residents (Resident (R) 37) reviewed for abuse out of 25 sample residents. This had the potential to affect resident safety in the facility. Findings include: Review of the facility's policy titled, ABUSE, PREVENTION AND PROHIBITION POLICY, revised 01/24, revealed Resident abuse must be reported immediately to the Administrator', The facility Administrator will ensure a thorough investigation of alleged violations of resident rights and document appropriate action While a facility investigation is under way steps will be taken to prevent further abuse. If a person is identified in the allegation of abuse, that person will not be allowed to have access to the facility while the investigation is in Progress' except to meet with the administrator, as part of the investigation process. The person identified in the allegation of abuse will have no contact with residents or employees during the investigation process. Review of R37's Admission Record located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including depression and anxiety. Review of R37's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/24/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. During an interview on 06/25/24 11:31 AM, R37 stated she was abused by a staff member in the past. She stated that she had a procedure on her head to relieve swelling and that has affected her memory. But she stated the staff was Certified Nursing Assistant (CNA) 7 and after the incident occurred she wrote a four-page report about what happened on a yellow note pad and gave it to the former Assistant Director of Nursing (FADON) who then gave it to the former Administrator. She stated she asked that CNA7 was allowed to remain on her hall but was not allowed to come into her room to provide care for her or her roommate. She stated CNA7 used foul language towards her specifically the f-bomb, and she remembered it was physical, but she was unable to remember the specifics due to effects of stroke. She stated she still saw CNA7 all the time in passing and it did bother her sometimes because seeing her brought back unpleasant memories. She stated all she heard was how wonderful CNA7 was but then why did she have to be abusive towards her. During an interview on 06/27/24 at 10:39 AM, FADON stated she was the former ADON until April of 2024. She stated that R37 gave her a post it notes that CNA7 was rude to her and R37 did not want her to be her CNA anymore. FADON stated she thought it was around Summertime 2023. She stated she reported it to the Administrator. She stated she spoke with R37, but she could not remember what she meant by the staff was rude but there was nothing documented. She stated there was no documentation to show that the allegations were investigated. During an interview on 06/27/24 at 12:18 PM, CNA7 stated she provided care to R37 in the past, but it had been a long time. She stated she was asked by a charge nurse not to provide care to R37, but she was unable to remember which charge nurse it was. She stated that she was told by other residents that R37 made allegations that she called the resident a bitch and that she reported that to a charge nurse, but she was not sure who. She stated she was never interviewed about any of the allegations or asked to write a statement. She stated there was never any follow-up after she was removed from providing care to R37, but she was still allowed to work in the hall where R37's room was located. During an interview on 06/28/24 at 2:54 PM, the Director of Nursing (DON) stated the allegations should have been investigated to ensure safety for all the residents.

Based on record review, interview, and facility policy review, the facility failed to report an allegation of verbal abuse to the State Survey Agency (SSA) for one out of four residents (Resident (R) 37) reviewed for abuse out of 25 sample residents. This failure had the potential to affect resident safety at the facility. Findings include: Review of the facility's policy titled ABUSE, PREVENTION AND PROHIBITION POLICY, revised 01/24, revealed The facility employee or agent, who becomes aware of abuse or neglect, including injuries of unknown origin or alleged misappropriation of resident property, shall immediately report the matter to the facility Administrator or his/her designated representative in the Administrators absence. An employee or agent or any Covered individual will make or cause a report to be made to law enforcement and the facility. The Administrator, or his/her designated representative if Administrator is not present, will notify the Regional Corporate Nurse (if unavailable, the Director of Clinical Operations will be contacted). The facility Administrator, employee, or agent who is made aware of any allegation of abuse or neglect shall report or cause a report to be made to the mandated state agency per reporting criteria. Such reports may also be made to the local law enforcement agency in the same manner. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately to the Administrator. The person made aware of allegations of abuse or neglect OR the Administrator will report the allegations of abuse and neglect to the mandated state agency and law enforcement. The allegation will be reported no later than 2 hours, or per state regulations, after the allegation is made. Review of R37's Admission Record located in the Profile tab of the electronic medical record (EMR), revealed admission to the facility on [DATE] with diagnoses including depression and anxiety. Review of R37's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/24/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. During an interview on 06/25/24 11:31 AM, R37 stated she was abused by a staff member in the past. She stated that she had a procedure on her head to relieve swelling and that has affected her memory. But she stated the staff was Certified Nursing Assistant (CNA) 7 and after the incident occurred she wrote a four-page report about what happened on a yellow note pad and gave it to the former Assistant Director of Nursing (FADON) who then gave it to the former Administrator. She stated she asked that CNA7 was allowed to remain in her hall but was not allowed to come into her room to provide care for her or the roommate. She stated CNA7 used foul language towards her specifically the f-bomb, and she remembered it was physical, but she was unable to remember the specifics due to effects of stroke. R37 stated she still saw CNA7 all the time in passing and it did bother her sometimes because seeing her brought back unpleasant memories. She stated all she heard was how wonderful CNA7 was but then why did she have to be abusive towards her. During an interview on 06/27/24 at 10:39 AM, FADON stated she was the former ADON until April of 2024. She stated that R37 gave her a post it notes that CNA7 was rude to her and R37 did not want her to be her CNA anymore. FADON stated she thought it was around Summertime 2023. She stated she reported it to the Administrator at the time, but she did not think it was reported to the state. She stated she spoke with R37, but she could not remember what she meant by the staff was rude but there was nothing documented. She stated there was no documentation to show that the allegations were investigated. During an interview on 06/27/24 at 12:18 PM, CNA7 stated she had provided care to R37 in the past, but it had been a long time. She stated she was asked by a charge nurse not to provide care to R37, but she was unable to remember which charge nurse it was. She stated that she was told by other residents that R37 made allegations that she called the resident a bitch and that she reported that to a charge nurse, but she was not sure who. She stated she was never interviewed about any of the allegations or asked to write a statement. She stated there was never any follow-up after she was removed from providing care to R37, but she was still allowed to work in the hall where R37's room was located. During an interview on 06/28/24 at 2:54 PM, the Director of Nursing (DON) stated the allegations should have been reported to ensure the safety for all the residents. She stated after any allegation of abuse involving staff, that staff should be immediately removed from the care area and suspended pending the outcome of the investigation. She stated the charge nurse would be responsible for reporting the allegations of verbal abuse to management.

Based on record review and interview, the facility failed to ensure the care plan was revised for two of three residents (Resident (R) 345 and R3) reviewed for care plan accuracy of 25 sample residents. Specifically, the facility failed to identify the inaccurate medical diagnosis for R345 and did not revise the care plan to address hospice services for R3. Failure to update the care plan could result in the residents not receiving care to meet their specific needs. Findings include: 1. Review of R345's Admission Record in the Profile tab of the electronic medical record (EMR) revealed an admitted [DATE]. The Admission Record revealed a diagnosis of dehydration. Review of R345's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/16/24 and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the resident was cognitively intact. Review of R345's Care Plan under the Care Plan tab of the EMR, revealed [R345] has dehydration or potential fluid deficit as a focus area with an initiation date and revision date of 06/10/24. R345's Care Plan revealed Monitor and document intake and output as per facility policy, and Lab work: blood urea nitrogen (BUN), (test that measures the amount of urea nitrogen that's in blood), and creatinine, (waste product that comes from the digestion of protein in food and the normal breakdown of muscle tissue), as ordered, as interventions related to the focus area. Review of R345's EMR revealed there was no order for monitoring or documentation of fluid intake and urine output. Review of R345's EMR revealed there was no BUN and creatinine lab work ordered or having been completed and documented. During an interview on 06/27/24 at 1:54 PM, the Director of Nursing (DON) stated, His care plan could just be stating what we would do if there were no orders, to monitor labs and Input and Output (I/O's) and labs. He may have diagnosis for it, but it could be an old diagnosis. We will monitor it and see if it is an actual diagnosis, but like I said, it could be an old one. During an interview on 06/27/24 at 2:35 PM, the DON stated, He was here before. The previous care plan triggered dehydration. He had it as a diagnosis during his last stay and on his care plan then. We just haven't updated his care plan, yet which would not include the diagnosis of dehydration. Like I said, things have changed so much in the last two weeks. I don't know how things were run before, but we did things differently where I worked before. During an interview on 06/28/24 at 12:20 PM, Licensed Practical Nurse (LPN) 3 stated, Assistant Director of Nursing (ADON) 1, MDS Coordinator LPN (MDSCL), and MDS Coordinator RN (MDSCR) . enter the meds, treatments, MDS, and care plan on new admissions. If it's a previous resident, we have to do the same process as they're a new resident . If I see a diagnosis that is inaccurate (such as dehydration), I call the Dr. During an interview on 06/28/24 at 12:36 PM, the ADON1 stated, MDS does the initial care plans and baseline care plans if they have been a previous patient. The nurses implement the interventions and make any changes that day . MDS checks the accuracy. During an interview on 06/28/24 at 12:47 PM, the Assistant Director of Nursing (ADON) 2 stated, MDS is responsible for entering the diagnosis. They enter it in the EMR when they get the referral information. Then after they're admitted , it uploads as a new admission into the EMR. The care plan populates right away . The clinical team, (DON, ADONs, and MDS) verify the changes during the daily clinical meeting along with social services and therapy. Readmissions are treated the same way as a new admission MDS should check to be sure they're accurate. During an interview on 06/28/24 at 1:05 PM, MDSCL stated, MDSCR and I enter the diagnosis and baseline care plan . If they are a prior resident, we restart the old care plan . We still have within the five days to update the old care plans when they are readmitted . We should have gone through the old care plan and double checked it for accuracy, but it got missed. During an interview on 06/28/24 at 2:19 PM, the DON stated, The immediate care plans are done upon admission and automatically populate . Until [R345] was brought up, I didn't know MDS repopulated the old care plans and used them. They have five days to review them and correct them after admission. 26006 2. Review of R3's Admission Record, located in the Profile tab of the EMR, revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease/dementia with agitation. Review of R3's significant change MDS assessment, with an ARD of 05/21/24 and located in the MDS tab of the EMR, revealed she was rarely/never able to understand others or make herself understood and had severely impaired cognition. She received hospice services. Review of R3's June 2024 Administration Record under the Orders tab of the EMR revealed a physician's order, dated 05/08/24, to admit R3 to hospice services for a diagnosis of dementia. Review of R3's Care Plan, dated 06/05/24 and located in the Care Plan tab of the EMR, revealed, [R3] has a terminal prognosis r/t [related to] Alzheimer's Disease. However, there were no goals or interventions documented to address the terminal prognosis. The Care Plan also documented, Advanced Directive/End of Life Care Plan. [R3] is approaching the end of life at this time. However, the approaches only addressed her code status of Do Not Resuscitate and did not include the provision of hospice services. Review of the Collaborative Care Plan, dated 05/07/24 and located in R3's hospice binder at the Nurses' Station, revealed the plan was to provide nurse visits once per week, aide visits twice per week, and social work and chaplain visits once per month. Under Other treatment plans documented, Foley Cath [catheter] change, diet/feedings, lab tests/diagnostic tests (with hospice approval), medication - see medication list. The section to list the party responsible for providing the necessary treatment plan (whether hospice staff or facility staff) was left incomplete. During an interview on 06/28/24 at 8:23 AM, the Administrator stated the facility did not have a policy addressing coordination of care between the facility staff and the hospice provider. During an interview on 06/28/24 at 9:02 AM, Certified Nurse Aide (CNA) 4 stated she provided the care R3 needed on a daily basis and hospice provided extra care beyond the standard care the facility provided. She stated the hospice staff used a communication binder and communicated during each visit regarding the care provided. She stated the Care Plan would populate R3's Kardex to indicate what care needed to be provided. During an interview on 06/28/24 at 1:19 PM, the MDSCL stated the nursing staff communicated to her when a resident went on hospice, and the Care Plan should have been updated right away to address coordination of care with hospice. The MDSCL stated she noticed last night that R3's Care Plan did not include hospice services, so she had added that R3 was on hospice. She stated, however, that she had not yet seen the hospice documents and so had not included any information yet regarding coordination of care with hospice. During an interview on 06/28/24 at 1:58 PM, the DON stated coordination of care with hospice providers should have been included in the Care Plan, which would then populate the Kardex to communicate to the direct care staff. The DON stated the MDSC was responsible for inputting the hospice Care Plan as soon as hospice services were implemented, and the Care Plan should have reflected the services hospice was providing for R3.

Based on record review and interview, the facility failed to ensure a resident was free from unnecessary medications when one of five residents (Resident (R) 10) was given two separate doses of psychotropic medications without any documented clinical need for either medication of 25 sample residents. This failure had the potential to affect the safety of all residents who received psychotropic medications. Findings include: Review of R10's Admission Record located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE] and with diagnoses of depression and anxiety disorder. Review of R10's quarterly Minimum Data Set (MDS) under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 04/11/24, revealed a Brief Interview for Mental Status (BIMS) score of six out of 15 which indicated R10 had severe cognitive impairment. The resident was coded as being prescribed antipsychotic medication. Review of R10's Care Plan located under the Care Plan tab of the EMR, dated 01/09/24, revealed Administer Antipsychotic medication as ordered. Review of R10 Physician Orders located under the Orders tab in the EMR, dated 06/03/24, revealed start Lorazepam (anti-anxiety medication) one milligram (mg) by mouth every four hours (PO) (orally), PRN (as needed) for restlessness and/or agitation for 14 days and haloperidol 0.5 ml (milliliter) orally every four hours PRN for agitation for 14 days. Review of Treatment Administration Record (TAR) located under the Records tab in the EMR, dated June 2024, revealed on 06/11/24; one dose of Lorazepam one milligram was administered at 4:46 PM and it was effective. However, a dose of Haloperidol 0.5 ml was also administered at 5:45 PM. Further review revealed no behaviors charted for agitation or restlessness on 06/11/24. Review of a ''Nurse's Notes'' located in the EMR under the ''Notes'' tab and dated 06/11/24, revealed no documentation about any behaviors or justification for use of PRN Lorazepam or Haloperidol. During an interview on 06/28/24 at 9:18 AM, Registered Nurse (RN) 2 stated staff should have documented in progress notes when a resident was having behaviors that would require a PRN medication and it should also be documented on the TAR under the behavior monitoring. She stated after the initial dose was given staff should have checked in about 45 minutes to an hour to see if it was effective or not and if it was effective, staff would not have needed to administer a second dose of anything. She stated a PRN med should not have been given without justification and it would not have been appropriate to administer a second dose of Haldol if the Lorazepam was documented as effective and that would be unnecessary. During an interview on 06/28/24 at 2:48 PM, the Director of Nursing (DON) stated when administering a PRN medication, staff should have put a note into the progress notes justifying what they were administering the PRN for. The DON stated they should have checked within an hour for effectiveness, and if it was effective, another dose should not have been given. She stated it was not appropriate for either of the PRN medications to have been administered without documentation of justification, or for the second dose to have been administered when the first was effective.

Based on observations, interviews, and record review, the facility failed to ensure staff obtained physician's orders and assessed residents for safe administration of medication to be kept at the bedside for two of four sampled residents (Resident #1 and #2). The facility census was 96. The facility provided no policy on medication administration. 1. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/6/23, showed: -Cognitive skills intact; -Diagnoses included diverticulitis (an inflammation or infection in one or more pouches in digestive tract), diabetes (a disease that occurs when your blood sugar is too high), and rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein in blood). Review of care plan, dated 11/6/23, showed the staff were to administer medications as ordered. Review of physician's orders, dated 11/8/23, showed no orders for medications at bedside. Review of electronic medical record on 11/8/23 showed no assessments for self-administration of medications. During an interview and observation on 11/8/23 at 9:45 A.M., Resident #1 was lying in his/her bed with two clear pill cups on his/her bedside table. One pill cup showed a blue pill and the other cup had a white pill. The resident said the blue pill was his/her antibiotic and he/she thought the nurse brought in his/her medications around 9:00 A.M. 2. Review of Resident #2's MDS, dated [DATE], showed: -Cognitive skills intact; -Diagnoses included generalized muscle weakness, chronic obstructive pulmonary disorder (COPD), dysphagia (difficulty in swallowing), and unsteadiness on feet, cognitive communication deficit (difficulty with thinking and how someone uses language). Review of care plan, dated 9/17/23, showed the staff were to administer medications as ordered. Review of physician's orders, dated 11/8/23 , showed: -no orders for medications at bedside; -1.0 cal/cc supplement one time a day for protein supplement -Blood glucose monitoring before meals and at bedtime -Apixaban oral tablet 5 mg, give 1 tablet by mouth two times a day for deep vein thrombosis -Artificial teals ophthalmic solution, instill 1 drop in both eyes one time a day for dry eyes -Budesonide-Formoterol Fumearate inhalation aerosol 160-4.5 mcg/act, 2 puff inhale orally two times a day for COPD rinse mouth with water after use, do not swallow -Carvedilol tablet 3.125 mg, give 1 tablet by mouth two times a day for hypertension -Famotidine tablet 20 mg, give 1 tablet by mouth in morning for acid indigestion -Fluticasone Propionate nasal suspension 50 mcg/act, 1 spray in both nostrils two times a day for allergies -Gabapentin oral capsule 300 mg (give 1 capsule by mouth one time a day for neuropathy -Incruse ellipta inhalation aerosol powder breath activated 62.5 mcg/act, 1 puff inhale orally one time a day for COPD, rinse mouth with water after use, do not swallow -Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-Injector 100 Unit/ml, inject as per sliding scale: if 151-200 = 3, 201-250 = 5, 251-300 = 8, 301-350 = 10, 351-400 =12, 401-450 = 15, subcutaneous before meals and at bedtime. Notify doctor if lower than 70 or higher than 350. -Lasix oral tablet 20 mg (furosemide), give 1 tablet by mouth one time a day for congestive heart failure -Levalbuterol HCl inhalation nebulization solution 0.63 mg/3 ml, 3 ml inhale orally via nebulizer two times a day for COPD, rinse mouth with water after use, do not swallow -Lidocaine external patch 4%, apply to sternum topically one time a day for pain and remove per schedule -Losartan potassium oral tablet 25 mg, give 0.5 tablet by mouth one time a day for hypertension. -tizanidine hcl oral tablet 2 mg, give 0.5 tablet by mouth in the morning for spasms Review of Medication administration record on 11/8/23, showed: -7:00 A.M. medication pass included administration of following: -1.0 cal/cc supplement one time a day for protein supplement -Artificial tears ophthalmic solution, instill 1 drop in both eyes one time a day for dry eyes; -Famotidine Tablet 20 mg, give 1 tablet by mouth in the morning for acid indigestion -Gabapentin oral capsule 300 mg, give 1 capsule by mouth one time a day for neuropathy -Incruse Ellipta Inhalation Aerosol Powder Breath Activated 62.5 MCG/ACT, 1 puff inhale orally one time a day for COPD rinse mouth with water after use, do not swallow -Lasix oral table 20 mg (furosemide), give 1 tablet by mouth one time a day for congestive heart failure -Levalbuterol Hcl Inhalation Nebulization solution 0.63 mg/3 ML, 3 ml inhale orally via equalizer in the after afternoon for COPD rinse mouth with water after use, do not swallow -Lidocaine External Patch 4% (lidocaine), apply to sternum topically one time a day for pain and remove per schedule -Losartan Potassium oral tablet 25 mg, give 0.5 tablet by mouth one time a day for high blood pressure -Tizanidine Hcl oral tablet 2mg, give 0.5 tablet by mouth in the morning for spasms -Apixaban oral tablet 5mg, give 1 tablet my mouth two times a day for deep vein thrombosis -Budesonide-formoterol fumarate inhalation aerosol 160-4.5mcg/act, 2 puff inhale orally two times a day for COPD rinse mouth with water after use, do not swallow -Carvedilol tablet 3.125 mg, give 1 tablet by mouth two times a day for hypertension -Fluticasone Proionate nasal suspension, 50 mcg/act, 1 spray in both nostrils two times a day for allergies; -Levalbuterol Hcl inhalation nebulization solution 0.63 mg/3 ml, inhale orally via nebulizer two times a day for COPD, rinse mouth with water after use, do not swallow -Blood glucose monitoring before meals and at bedtime: 153 at 0600 -Insulin Lispro (1 unit dial) subcutaneous solution pen-injector 100 unit/ml, inject per sliding scale: if 151-200 = 3, 3 units administered. Review of electronic medical record on 11/8/23 showed no assessments for self-administration of medications. During an interview and observation on 11/8/23 at 10:04 A.M., the resident was lying on his/her bed with medications at bedside table. Observation showed a fluticasone 50 mcg nasal spray (a medication used to treat allergies), incruse ellipta 62.5mcg (used to treat COPD), budesonide and formoterol fumactate dehydrate inhalation 160 mg inhalers (used to treat COPD), and two pill cups. One medication cup contained a yellow pill, one white round pill, 1/2 a white pill, 1 white oval pill and one pink pill. The second medication cup showed a larger pink tablet. During an interview on 11/8/23 at 1:38 P.M., the resident said he/she had other residents wander into his/her room. 3. During an interview on 11/8/23 at 12:49 P.M., Regional Nurse A said: -Facility did not have a medications at bedside policy or self-administration of medications policy. -Facility would allow residents to self-administer medications but a medication administration assessment would have been competed on those residents and located in electronic medical record. During an interview on 11/8/23 at 1:27 P.M., Licensed Practical Nurse (LPN) A said: -The staff should not leave medication on residents bedside table. During an interview on 11/8/23 at 1:33 P.M., Registered Nurse (RN) A said: -He/She passed medications this morning to Resident #1 and Resident #2; -The medication administration practice included watching residents take their medications; -He/She left medications at the bedside for Resident #1 because he/she preferred to take antibiotics over a period of time as his/her medications make them nausea. -He/She did not know if Resident #1 had orders to self-administer his/her medications' -Resident #1 was alert and orientated; -He/She watched Resident #2 take his/her medications. During an interview on 11/8/23 at 1:48 P.M., Certified Medication Technician (CMT) A said: -He/She said it was not okay to leave medications at bedside with a resident; -He/She found residents with medications at his/her bedside who were not cognitively aware and reported it to nurse when he/she found the medications; -He/She has found medications after overnight shift had passed medications. During an interview on 11/8/23 at 1:53 P.M., LPN B said: -Standard practice was to wait with resident while they take their medications to ensure they take the medications; -Inhalers can only be left at bedside if a doctor orders them; -No medications should be left at bedside unless approved by doctor. During an interview on 11/8/23 at 1:56 P.M., the Administrator said: -He/She would expect medications left at beside to have a physician's order; -Residents that self-administer medications should have an assessment completed and a physician's order. During an interview on 11/8/23 at 2:06 P.M., the Assistant Director of Nursing (ADON) said: -He/She expected staff to stay and watch the resident take their medications during the medication pass; -Medications should not be left on the bedside table; -An assessment should be completed on residents who self-administer their own medications. MO226709

Based on interview and record review, the facility failed assess, treat, and reassess two sampled residents (Resident #1 and #2) for complaints of pain after Resident #1 fell from the sit-to-stand mechanical lift on 10/2/21 and after Resident #2 had a witnessed fall from his/her wheelchair on 10/2/21. The facility failed to seek pain treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was diagnosed with a fracture to the right femur (upper leg bone) and Resident #2 was diagnosed with a fracture of the left ankle. The facility census was 87. The Administrator was notified on 10/5/21 at 4:55 P.M. of an Immediate Jeopardy (IJ) which began on 10/2/21. The IJ was removed on 10/6/21, as confirmed by surveyor onsite verification. The facility did not provide a policy directing staff on when to assess residents for pain. Review of the undated significant condition change and notification policy showed: - The facility will notify the resident's family and/or representative and primary care provider regarding a change in condition of the resident. Examples of a change in condition include; - An accident or incident with or without injury that has the potential for medical professional intervention. - A significant change in the resident's physical status include: Mobility changes, onset of swelling, and abnormal or new complaints of pain. - Prior to calling the medical practitioner, the nurse will complete the Situation, Background, Assessment, Recommendation (SBAR) assessment. 1. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment tool that is completed by the facility staff), dated 8/12/21, showed: - The resident was admitted to the facility on [DATE]. - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . - Brief Interview for Mental Status (BIMS, an assessment that determines the resident's cognitive level), of 15, indicating the resident had little to no cognitive deficit. - Dependant on staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. - Required minimum assistance with locomotion in the wheelchair. Review of the resident's pain care plan, dated 8/22/20, showed: - Monitor and report complaints of pain or the request for pain medication to the nurse. - Notify the physician if interventions are unsuccessful. - Notify the physician of the complaint of pain is a significant change from the resident's past experience with pain. - Monitor his/her pain characteristics such as if the pain was sharp or burning, the pain severity utilizing the one to 10 number scale (Zero to one indicates no pain, two to three indicates mild pain, four to five indicates moderate pain, six to seven indicates severe pain, eight to nine indicates very severe pain, ten indicates the worst possible pain), the location of the pain, the onset of the pain and the duration. - Administer medications as the physician has ordered. - Evaluate the effectiveness of the pain interventions. Review of the resident's activities of daily living, (ADL, activities that the individual requires for daily care) care plan, dated 9/2/21, showed: - Transfer with two staff and the mechanical lift. Review of the resident's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - Record his/her pain level per pain scale every shift. - Acetaminophen (medication used to treat mild to moderate pain) 325 milligrams (mg) by mouth every morning and at bedtime. - Acetaminophen 325 mg per tablet, give two tablets by mouth every four hours as need for mild pain (one to four on the pain scale). Do not give more than 3,000 mg in 24 hours. - Biofreeze gel 4% (a medicated topical gel used to treat mild pain of the muscles or joints), apply the gel topically on the legs and feet every six hours as needed for pain. - Biofreeze gel 4%, apply topically to the neck one time daily at bedtime for pain. During an interview on 10/4/21 at 7:35 P.M., Certified Nursing Assistant (CNA) E said: - He/she works for a staffing agency; - The facility staff gave him/her a printed sheet which indicated staff should transfer the resident using the sit-to-stand lift. - On 10/2/21 about 6:30 A.M., while staff provided morning care, the resident could not hold on to the sit-to-stand lift and he/she and another CNA lowered the resident to the floor. - He/she worked at the facility for the first time on 10/1/21, and did not receive orientation. - The charge nurse gave him/her a cheat sheet and told him/her the resident used the sit-to-stand lift. During an interview on 10/4/21 at 1:45 P.M., CNA A said: - He/she used the Kardex (an electronic version of the resident immediate care needs that the CNA's use to care for the resident's) to determine the resident transfer need. - The resident had recently changed to using the Hoyer lift (mechanical lift). - CNA A began his/her work day on 10/2/21 at 7:00 A.M., and saw CNA E using the sit-to-stand lift to transfer the resident. - The resident became confused and rubbing his/her thigh about noon on 10/2/21. - He/she reported the change in condition to Licensed Practical Nurse (LPN) A who gave the resident acetaminophen and applied a cream to the resident's leg. - CNA A reported to LPN A the resident held his/her thigh and moaned when staff rolled him/her side to side to provide care to the resident on 10/2/21. Review of the resident's nurses' progress notes showed: - 10/2/21 at 12:04 P.M., acetaminophen 325 mg per tablet, two tablets were administered to the resident and the staff did not document a pain assessment or no follow up was documented. - An undated and un-timed nurse's note written by LPN A said the therapist reports to him/her the resident complains of right leg pain. The resident reported to LPN A that his/her right leg hurt. LPN A documented that he/she was unable to assess the resident's leg due to the resident was wearing tight pants, however was able to see the calf and noted no swelling or redness. LPN A applied Biofreeze Gel to the resident's right calf and administered as needed acetaminophen and intervention was ineffective. - 10/2/21 at 1:21 P.M., the resident experiencing a change in condition and a SBAR is written. Review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -No pain assessment documented for 10/2/2021. -No documentation of administration of Tylenol or Biofreeze on 10/2/2021. Review of the SBAR, dated 10/2/21 at 1:21 P.M., showed: - Situation: Resident complains of right leg pain, started on 10/2/21, and worsens with movement. - Mental Status Changes: not applicable. - Request: Monitor vital signs. During an interview on 10/4/21 at 12:35 P.M., Physical Therapy Assistant (PTA) A said: - He/she going to do therapy with the resident, but the resident complained of knee pain at breakfast on 10/2/21 and declined to participate in therapy. - He/she reported this to the nurse and the nurse said he/she would apply some Biofreeze to the resident's knee. - The PTA checked on the resident at lunch and he/she was still in bed complaining of right knee pain. - The PTA checked on the resident about 4:00 P.M. and found the resident in bed with his/her knee propped in a bent position. - The resident was writhing in pain and had noticeable swelling of the right knee. - The PTA could not reposition the resident's knee, because he/she cried out. - The PTA reported the increase of pain to the charge nurse again. Review of the resident's nurses' progress notes showed: - 10/2/21 at 4:38 P.M., acetaminophen 650 mg was given to the resident, an initial pain scale rating was not documented, the follow up pain scale rating was three and the medication was ineffective. - No nurses notes regarding the resident between 4:38 P.M. and 9:00 P.M. on 10/2/21. - 10/2/21 at 9:00 P.M., staff completed a second SBAR assessment due to the resident's increased pain, swelling and warmth to his/her right knee. LPN C documented the resident was grimacing and having discomfort when the staff attempted to touch the resident. The resident was unable to straighten the leg or bend at the knee due to increased pain. LPN C notified the Assistant Director of Nursing (ADON), and paged the on-call physician and notified the resident's Durable Power of Attorney (DPOA). Review of the resident's SBAR, dated 10/2/21 at 9:00 P.M., showed: - Situation: Increased pain, swelling, and warmth to the right knee. - Started on 10/2/21 and had worsened. - Things that worsens the pain: Attempting to straighten the right leg, turning while in bed, and raising the extremity. - Request: Monitor vital signs and X-ray (a picture of the bones) of the right knee. Review of the resident's nurses' progress notes showed: - 10/2/21 at 9:19 P.M., the staff gave acetaminophen to the resident. LPN C documented he/she was still awaiting a return call from the on-call physician for further orders. Staff documented the pain was not relieved. During an interview on 10/4/21 at 5:05 P.M., CNA D said: - He/she cared for the resident on 10/2/21 from 3:00 P.M. to 7:00 A.M. - He/she reported to the charge nurse the resident's complaints of pain. - The resident screamed in pain when he/she changed his/her soiled brief. He/She reported this to the charge nurse. Review of the resident's MAR, dated October 2021, showed: - Staff documented they administered the resident's scheduled acetaminophen on 10/3/21 at 6:00 A.M., but did not document they rated the resident's pain; - Staff documented they administered as needed (prn) acetaminophen on 10/3/21 at 8:00 A.M. and the resident rated his/her pain at a nine. During an interview on 10/4/21 at 4:20 P.M., CNA B said: - He/she worked 7:00 A.M. to 11:00 P.M. on 10/2/21 and 10/3/21. - He/she told the charge nurse the resident was in pain on 10/2/21 around 9:00 P.M. - The resident cried out when he/she rolled the resident to provide care whenever the resident was moved during the entire shift. Review of the resident's nurses' progress notes showed: - 10/3/21 at 2:00 A.M., LPN C documented the on-call nurse practitioner returned the call and LPN C told the nurse practitioner of the resident's current condition with pain and asked for an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident still had swelling of the right knee. - 10/3/21 at 4:52 A.M., LPN C documented the nurse practitioner called with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse called a mobile X-ray company with the order for two-views of the right knee. The technician will be out in the morning to perform the X-ray. - 10/3/21 at 11:43 A.M., the X-ray results are called to LPN A and showed an extensive displaced fracture (broken bone that is not in alignment) of the right femur (a large bone in the upper leg). New order to send the resident to the emergency room . LPN C called 911 and the resident left the facility by ambulance on 10/3/21 at 11:33 A.M. -No documentation staff administered any pain medication to the resident at these times. Review of the resident's SBAR, dated 10/3/21 at 1:21 P.M., showed: - Staff only included the resdient's vital signs and no other information on the form. - Blood pressure 125/50, pulse 73 per minute, respirations 20 per minute, temperature 98.7 Fahrenheit. During an interview on 10/4/21 at 4:26 P.M., LPN A said: - He/she cared for the resident on 10/2/21 and 10/3/21 on the day shift. - The change of shift report did not mention an injury to the resident. - The resident complained of right leg and knee pain at lunch time. - The resident was squirming in his/her wheelchair and rubbing his/her right leg. - LPN A gave the resident acetaminophen and applied Biofreeze to the leg. - On 10/3/21, the resident was in pain when staff moved him/her. - He/she assessed the resident's right leg and found he/she had swelling to the right knee. - LPN A called the resident's physician and obtained a new order for an X-ray, which was done between 7:00 A.M. and 8:00 A.M. on 10/3/21. - The resident stayed in bed sleeping. - The resident cried out when the staff moved him/her on both days. - He/She said he/she did not think the resident was in pain on 10/2/21 and that is why he/she did not notify the doctor that day of the pain. Review of the resident's hospital records, dated 10/3/21 at 11:46 A.M., showed: - The resident had a witnessed accident that resulted in his/her right femur fracture. - Resident arrived at the hospital with intractable (pain that is difficult to treat and manage) pain to the right leg. - Pain rated at eight out of ten, indicating severe pain. - Increased confusion. - Pain control was achieved through oral and intravenous (medication placed through the vein with needle) pain medication. - The resident required surgery on 10/4/21 to fix the fracture of the right leg. 2. Review of Resident #2's significant change in condition MDS, dated [DATE], showed: - admitted [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . - BIMS of 0 indicating the resident was severely impaired cognitively. - The resident was dependent on the staff for bed mobility, transfers, locomotion in his/her wheelchair, toilet use, and personal hygiene. Review of the resident's care plan, updated 10/4/21, showed: - Falls: The resident is at risk for falls due to weakness and confusion. Adjust the wheelchair for better positioning. Tilt back wheelchair ordered on 10/2/21. Remind resident not to lean forward in the wheel chair. - Pain: Report to the nurse any symptoms or signs of pain. Non-verbal signs a include labored or noisy breathing that increases in speed, grunts, moans, yelling out, increased restlessness, crying, and grimacing of the face. Administer pain medications as ordered. Review of the resident's POS, dated October 2021, showed: - 6/2/21 ordered record the resident's pain scale every shift using the one to ten pain scale. Zero to one indicates no pain, two to three indicates mild pain, four to five indicates moderate pain, six to seven indicates severe pain, eight to nine indicates very severe pain, ten indicates the worst possible pain. - 6/2/21 ordered Acetaminophen 325 mg per tablet, give two tablets by mouth every six hours as needed for mild pain. - 6/2/21 ordered [MEDICATION(S)] Cream 4% (a topical cream that numbs the area that it is placed), apply 4 grams (a unit of measure) to the resident's low back two times daily for back pain. Review of the resident's nurses' progress notes showed: - On 10/2/21 at 7:07 A.M., the resident was at the nurses' station and had a witnessed fall. - Staff observed the resident slide off the wheelchair seat onto the floor on his/her buttocks. - Foot rests are in the down position. - No injuries seen. - No documentation of a pain assessment. During an interview on 10/4/21 at 4:55 P.M., LPN B said: - The resident fell during change of shift report while at the nurses' desk. - The resident fell out of the wheelchair and staff found him/her on his/her hands and knees with feet caught under a chair. - He/she helped the resident to a sitting position with a gait belt (a belt used for transfers). - He/she assessed the resident and did not find any injuries or pain. - He/she notified the resident's spouse and the physician on 10/2/21 at 7:07 A.M. - X-Ray order was obtained on 10/2/21 at 6:02 P.M. - The PTA told him/her the resident complained of pain around noon. - The CNA reported later that night the resident complained of ankle pain on 10/2/21 around 9:00 P.M. - The mobile X-ray was not done right away, because the X-ray was not ordered stat (immediately). Review of the SBAR, dated 10/2/21 at 7:07 A.M., showed: - Blood pressure 141/54, indicating a high blood pressure. - Plan to monitor vital signs. - The resident's spouse was notified of the fall. - The on-call physician was notified of the fall. - No documentaion regarding pain. During an interview on 10/4/21 at 12:35 P.M., PTA A said: - The resident was discharged from hospice services one week ago, because he/she improved in condition and was doing therapy five times per week. - The nursing staff reported the resident slid from his/her wheelchair at the nurses' desk on Saturday morning, 10/2/21, while he/she was leaning forward. - The resident complained of pain with range of motion exercises on Saturday morning to PTA A. - The ankle was swollen. - PTA told the nurse something was wrong with the resident's ankle. During an interview on 10/4/21 at 4:23 P.M., CNA C said: - He/she worked the day shift on 10/2/21 and 10/3/21. - The resident acted fine on 10/2/21 on the day shift and did not complain of any pain. - The resident developed a fever on 10/3/21 and would not get out of bed due to pain. Review of the resident's nurses' progress notes showed: - 10/2/21 at 6:02 P.M., the PTA told LPN B the resident complained of left ankle pain when standing and the ankle was swollen. LPN B contacted the primary care physician and obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] - 10/2/21 at 9:16 P.M., the X-ray technician called and spoke with LPN C to inform the nurse the X-ray was scheduled for 10/3/21 in the morning. - 10/3/21 at 12:49 A.M., LPN C documented the resident had swelling in the left ankle. No documentaion of a a pain assessment. - 10/3/21 at 8:08 A.M., LPN B documented staff gave acetaminophen 325 mg per tablet, two tablets to the resident for pain. Staff did not complete the pain rating or follow up for effectiveness. - 10/3/21 at 10:40 A.M., Certified Medication Technician (CMT) A documented he/she did not administer the resident's medications per the nurse's instruction held per charge nurse instruction. - No further documentation in the nurses' notes regarding pain assessments or the administration of pain medication. Review of the resident's hospital records, dated 10/3/21 at 11:19 A.M., showed: - The resident arrived at the hospital by ambulance. - The resident slipped out of his/her wheelchair yesterday and injured the left ankle. - An X-ray showed a fractured left ankle with dislocation. - The facility staff reported the resident had increased confusion over the past two days. - Hospital staff documented the resident was writhing in pain. - The hospital staff realigned the broken bones and placed a splint to keep the bones from moving. - The resident was not a candidate for surgery due to worsening of other health conditions. - The resident was referred to receive care from a hospice house. During an interview on 10/4/21 at 5:13 P.M., LPN C said: - The resident complained of pain on 10/2/21 around noon. - The nurse said he/she should assess the residents' for pain relief and notify the PCP if pain relief measures did not work. - The resident slid out of his/her wheelchair at the nurses' station. - He/she has swelling to both ankles. 3. During an interview on 10/5/21 at 11:27 A.M., the primary care physician (PCP) said: - He/she expected the nurses to assess the residents for pain and injury and contact the PCP or on-call provider for new orders when needed. - We try to manage symptoms of pain in the facility as much as possible. - It is the nurse's role to assess the resident for pain and should they treat the pain and call the doctor if the pain med is not effective. During an interview on 10/4/21 at 12:05 P.M., the ADM and the DON said: - They expected staff to notify a resident's physician by phone if pain relief interventions did not relieve pain. - They expected staff to assess whether pain relief interventions provided relief. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 8, MO 6, MO 9

Based on interview and record review, the facility failed to ensure all staff were trained and informed of each resident's individual care needs. The facility identified Resident #1 required a Hoyer lift (mechanical lift used for residents who required total assistance for transfers). On 10/2/21, staff transferred the resident using a sit to stand (STS, type of mechanical lift that required a resident to be able to bear weight). During the transfer, the resident was unable to hold on to the lift, was assisted to the floor, and sustained a femur fracture. The facility census was 87. The Administrator was notified on 10/5/21 at 4:55 P.M. of an Immediate Jeopardy (IJ) which began on 10/2/21. The IJ was removed on 10/6/21, as confirmed by surveyor onsite verification. Review of the undated policy on agency personnel check list showed: - Facility staff must review the check list with agency personnel prior to providing care with residents. - This check list must be signed by the agency staff and facility staff and returned to the facility. - The check list covered the use of facility software and electronic charting. - Use of the electronic Kardex (an electronic device written by facility staff for Certified Nurse Assistants to read how to care for residents). Review of the facility policy, dated 9/17/19, on falls showed: - The purpose of the policy was to prevent falls and manage interventions that foster resident independence and quality of life. - The definition of a fall was the unintentional coming to rest on the ground, floor, or other lower level. - If a resident lost balance and would have otherwise fallen if not for someone intervening, it was considered a fall. 1. Review of Resident #1's undated Certified Nurse Assistant (CNA) Kardex showed for transfers the resident required two staff members using a Hoyer lift. Review of the resident's care plan, dated 5/21/21, showed: - The resident had a self care deficit due to muscle weakness and spinal stenosis (narrowing of the spinal cord resulting in weakness). - Staff required the use of a STS mechanical lift for transfers using two staff members. - Staff did not update the care plan stating staff should use a Hoyer lift for transfers. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/12/21, showed: - Cognitively intact; - Required extensive staff assistance for transfers; - Required total staff assistance for toileting; - Used a wheelchair; - Always incontinent of bladder and frequently incontinent of bowel; - Diagnoses included diabetes, stroke, dementia, and depression; - No falls. Review of the resident's care plan, dated 8/23/21 showed: - The resident was at risk for falls due to confusion, deconditioning, medications, and a history of falls with injury. - Goal the resident would be free of falls. - No interventions documented for falls. During an interview on 10/4/21 at 7:37 P.M., CNA E said: - He/she worked for a staffing agency. - He/she had never worked in the facility until working the night shift starting 10/1/21 at 7:00 P.M. and ending 10/2/21 at 7:00 A.M. - CNA E did not receive any facility orientation. - CNA E received a printed cheat sheet, which included how to transfer residents, from Licensed Practical Nurse (LPN) C when he/she started the shift. - The cheat sheet indicated the resident used a STS for transfers. - During change of shift report the off going staff did not tell CNA E how to transfer the residents. - LPN C told CNA E to transfer the resident using the STS. - He/She was not shown how to access the Kardex. - He/she was getting the resident up in the morning using the STS. - He/she took the resident to the toilet and was returning the resident to the resident's wheelchair using the STS. - Another CNA walked by the room and said the resident should be transferred using a Hoyer. - The resident was holding on to the STS and could not hold on. - Both CNAs lowered the resident to the floor and called the charge nurse. During an interview on 10/4/21 at 5:17 P.M., LPN C said: - He/she was the charge nurse for the resident on 10/1/21 starting at 7:00 P.M. through 10/2/21 at 7:00 A.M. - He/she did not review the agency check list with CNA E. - He/she printed a cheat sheet, which included diet and how to transfer residents for CNA E when he/she came to work. - The cheat sheet said the resident was to be transferred by STS. - CNA E got the resident up using the STS and took the resident to the toilet. - After toileting the resident, CNA E used the STS to transfer the resident to his/her wheelchair. - The resident could not hold on to the STS. - CNA E lowered the resident to the floor. - LPN C said he/she did not feel this constituted a fall. - LPN C checked the resident who was fully dressed. Review of the resident's nurses' notes, dated 10/2/21, showed no documentation regarding the resident being lowered to the floor. During an interview on 10/4/21 at 12:05 P.M., the Administrator (ADM) and the Director of Nursing (DON) said: - The resident was supposed to be transferred by two staff using a Hoyer. - The night shift staff used one person with a STS transfer. - The staff was moving the resident from the toilet to bed using the STS. - The resident was holding on to the STS and then could not hold on to the STS any longer. - The staff member lowered the resident to the ground. - The charge nurse did not think the resident fell and did not report the resident being lowered to the floor to the on coming nurse, the resident's physician, or the resident's responsible party. During an interview on 10/4/21 at 12:40 P.M. Physical Therapy Assistant (PTA) A said: - He/she walked in at breakfast to work with the resident who complained of right knee pain. - PTA A said he/she would return later. - He/she told the charge nurse who applied prn Biofreeze and administered Tylenol. - He/she went back later for therapy after lunch and found the resident writhing in pain. - The resident's knee appeared swollen and appeared worse than was normal for the resident. - He/she deferred therapy due to the resident writhing in pain. - He/she reported the incident to the charge nurse around noon. During an interview on 10/4/21 at 1:45 P.M., CNA A said: - Staff changed the resident's Kardex recently to a Hoyer transfer. - CNA A came to work on 10/2/21 at 7:00 A.M. - CNA E gave CNA A change of shift report. - CNA E said he/she used the STS to transfer the resident and the resident could not hold on the STS. - CNA E lowered the resident to the floor. - Around 12:00 P.M. the resident was rubbing his/her thigh. - The charge nurse put cream on the resident's thigh. - The resident held his/her thigh and moaned in pain. - CNA A notified the charge nurse that the resident was in pain. During an interview on 10/4/21 at 4:25 P.M., LPN A said: - He/She was the resident's charge nurse on 10/2/21 from 7:00 A.M. through 7:00 P.M. - Around lunch the resident complained of right leg and knee pain while the resident was sitting in the dining room. - LPN A applied prn Biofreeze to the areas he/she could reach, but did not remove the resident's pants and administered Tylenol. - The resident kept rubbing his/her leg. During an interview on 10/4/21 at 4:20 P.M. CNA B said: - He/she worked 10/2/21 at 3:00 P.M. until 10/3/21 at 7:00 A.M. - The resident was in a lot of pain the entire shift. - Whenever CNA B tried to roll the resident, the resident would cry out in pain. - CNA B notified the charge nurse around 9:00 P.M. on 10/2/21. Review of the resident's Situation, Background Assessment and Request (SBAR), dated 10/2/21 at 9:00 P.M. by Licensed Practical Nurse (LPN) C showed: - The resident had increased pain, swelling, and warmth to the right knee. - Turning, raising, attempting to straighten the knee increased pain. - LPN C notified the Nurse Practitioner (NP) on call. During an interview on 10/4/21 at 5:17 P.M. LPN C said: - He/she was the charge nurse on the night shift starting 10/2/21 at 7:00 P.M. through 10/3/21 at 7:00 A.M. - When the resident complained of knee pain, he/she applied prn Biofreeze and administered prn Tylenol. - The resident was comfortable at rest, but quite uncomfortable when moved. - He/she notified the on call NP around 9:00 P.M. on 10/2/21. - The on call NP called back around 1:00 A.M. on 10/3/21 and said he/she would speak with another NP about ordering an X-ray. - The on call NP called back around 4:00 A.M. with an order for an X-ray. - When he/she assisted the CNA with turning the resident the resident moaned in pain during care. Review of the resident's nurses' notes by LPN C, dated 10/2/21 at 9:19 P.M. showed: - Staff reported to LPN C that the resident complained of increased right knee pain. - Assessment by LPN C showed the resident could not straighten the knee, with swelling, warmth, and redness of the knee. - LPN C notified the nurse practitioner and the Director of Nursing (DON) on call. - LPN C applied Biofreeze and administered ordered as needed (prn) Tylenol. Review of the resident's nurses' notes, dated 10/3/21 at 4:52 A.M., by LPN B showed: - The nurse practitioner called an order for X-ray to the resident's right knee due to swelling, increased pain, and warmth to touch. - LPN B notified the mobile X-ray provider. Review of the resident's nurses' notes, dated 10/3/21 at 11:43 A.M., by LPN A showed: - X-ray report showed displaced (a break in a bone where the bone pieces do not match up) fracture involving the right femur (upper leg bone); - The on call NP gave an order to send the resident to the emergency department. During an interview on 10/4/21 at 4:25 P.M. LPN A said: - On 10/3/21 the resident stayed in bed due to pain on 10/3/21 until sent to the hospital. - On 10/3/21 a mobile X-ray was performed. - On 10/3/21 LPN A called the resident's on call NP with the X-ray report. - After receiving an order to transport the resident from the resident's NP, LPN A had the resident transported to a local emergency department (ED). Review of the resident's medical records from a local hospital, dated 10/3/21 at 11:46 A.M. showed: - Chief complaint right leg pain. - The resident was noted to have increased pain in his/her right leg. - The resident had increased confusion. - There was no report of trauma. - The resident rated the pain as an 8 on a 1-10 scale. - Assessment showed a right femur fracture with intractable pain (unrelieved pain) due to the femur fracture. - X-ray report showed a displaced femur fracture. - The resident was taking to surgery for repair of the fracture. During an interview on 10/5/21 at 9:55 A.M. the DON said: - He/she expected all staff to use the Kardex to find out how to transfer residents. - The charge nurse should review the agency staff check list before any new agency staff start work. - The charge nurse should consider a fall as any time a resident was lowered to the floor. - Staff should not hand out cheat sheets to any staff. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 6, MO 6, MO 8, MO 9

Based on interview and record review, the facility failed to thoroughly assess two sampled residents (Residents #1 and #2) after the residents fell and sustained injuries and failed to notify the resident's physicians after the falls. The facility failed to ensure that staff understood the definition of all falls which affected one resident (Resident #1). The facility staff also failed to thoroughly assess one resident (Resident #4) after an allegation of injury. The facility census was 87. The Administrator was notified on 10/5/21 at 4:55 P.M. of an Immediate Jeopardy (IJ) which began on 10/2/21. The IJ was removed on 10/6/21, as confirmed by surveyor onsite variation. The facility did not provide a post fall assessment policy. Review of the undated facility policy on significant condition change and notification, showed: - The purpose of the policy was to ensure that the resident's responsible party and medical provider were notified if a resident fell with or without injury. - The resident's medical provider must be notified immediately for any emergencies. - Staff must document notifying the resident's medical provider. Review of the undated policy on agency (a staffing agency) personnel check list showed: - Staff must review the check list with all agency staff prior to the staff providing resident care. - Kardex (an electronic record generated by facility staff) showing resident transfer type. Review of the facility policy, dated 9/17/19, on falls showed: - The purpose of the policy was to prevent falls and manage interventions that foster resident independence and quality of life. - The definition of a fall was the unintentional coming to rest on the ground, floor, or other lower level. - If a resident lost balance and would have otherwise fallen if not for someone intervening, it was considered a fall. Review of the facility policy, dated February 2021, on fall prevention showed: -The SAFE program promoted Safety, Assessment, Fall prevention and Education of staff and residents. - Following any fall, staff will discuss the fall at the daily fall risk meeting. Review of the facility policy, dated February 2021, on charting showed: - Staff must chart all pertinent changes in a resident's condition. - Staff must be complete and concise in observations. - Staff must chart the date and time the resident's family and physician were notified. - Staff must document every shift for 72 hours post change in condition. 1. Review of Resident #1's undated Certified Nurse Assistant (CNA) Kardex showed for transfers the resident required two staff members using a Hoyer (mechanical lift used for residents who require total assistance for transfers). Review of Resident #1's care plan, dated 5/21/21, showed: - The resident had a self care deficit due to muscle weakness and spinal stenosis (narrowing of the spinal cord resulting in weakness). - Staff required the use of a sit-to-stand lift (STS, a mechanical lift requiring the resident to bear weight and used for transfers using two staff members). - Staff did not update the care plan stating staff should use a Hoyer for transfers. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/12/21, showed: - Cognitively intact; - Required extensive staff assistance for transfers; - Required total staff assistance for toileting; - Used a wheelchair; - Always incontinent of bladder and frequently incontinent of bowel; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - No falls. Review of the resident's care plan, dated 8/23/21, showed: - The resident was at risk for falls due to confusion, deconditioning, medications, and a history of falls with injury. - Goal the resident would be free of falls. - No interventions documented to prevent falls. During an interview on 10/4/21 at 7:37 P.M., CNA E said: - He/she worked for a staffing agency. - He/she had never worked in the facility until working the night shift starting 10/1/21 at 7:00 P.M. and ending 10/2/21 at 7:00 A.M. - He/she was getting the resident up in the morning using the STS. - He/she took the resident to the toilet and was returning the resident to the resident's wheelchair using the STS. - Another CNA walked by the room and said the resident should be transferred using a Hoyer. - The resident was holding on to the STS and could not hold on. - Both CNAs lowered the resident to the floor and called the charge nurse Licensed Practical Nurse (LPN) C about 6:30 A.M. -LPN C checked the resident. During an interview on 10/4/21 at 5:17 P.M LPN C said: - He/she was the charge nurse for the resident on 10/1/21 starting at 7:00 P.M. through 10/2/21 at 7:00 A.M. - CNA E got the resident up using the STS and took the resident to the toilet. - After toileting the resident, CNA E used the STS to transfer the resident to his/her wheelchair. - The resident could not hold on to the STS. - CNA E lowered the resident to the floor. - LPN C said he/she did not feel this constituted a fall. - LPN C checked the resident who was fully dressed. - LPN C did not remove the resident's clothing to assess the resident. - The resident always complained of pain when staff moved the resident's knee. Review of the resident's medical record for 10/2/21 showed no documentation of the resident's fall or assessment and notification of the physician after the fall. During an interview on 10/4/21 at 12:05 P.M., the Administrator (ADM) and the Director of Nursing (DON) said: - The resident frequently complained of knee pain. - The resident was supposed to be transferred by two staff using a Hoyer after the resident recently had a change in condition. - The night shift staff used a one person with a STS to transfer. - The staff was moving the resident from the toilet to bed using the STS. - The resident was holding on to the STS and then could not hold on to the STS anymore. - The staff member lowered the resident to the ground. - The charge nurse assessed the resident and did not find any evidence of injury. - The charge nurse did not think the resident fell and did not report the resident being lowered to the floor to on coming staff, the resident's physician, or the resident's responsible party. - The charge nurse should have notified the resident's medical provider and responsible party that the resident was lowered to the floor. - The charge nurse applied the resident's ordered as needed (prn) Biofreeze (a pain reliever rubbed in the skin) and prn Tylenol (a medication used to relieve minor pain). During an interview on 10/4/21 at 12:40 P.M., Physical Therapy Assistant (PTA) A said: -On 10/2/21 he/she walked in at breakfast to work with the resident who complained of right knee pain. - PTA A said he/she would return later. - He/she told the charge nurse who applied prn Biofreeze and administered Tylenol. - He/she went back later for therapy after lunch and found the resident writhing in pain. - The resident's knee appeared swollen and appeared worse than was normal for the resident. - He/she deferred therapy due to the resident writhing in pain. - He/she reported the incident to the charge nurse after lunch. During an interview on 10/4/21 at 1:45 P.M., CNA A said: - CNA A came to work on 10/2/21 at 7:00 A.M. - CNA E gave CNA A change of shift report. - CNA E said he/she used the STS to transfer the resident and the resident could not hold on the STS. - CNA E lowered the resident to the floor. - Around 12:00 P.M. on 10/2/21 the resident was rubbing his/her thigh. - The charge nurse put cream on the resident's thigh. - The resident held his/her thigh and moaned in pain. - CNA A notified the charge nurse that the resident was in pain. During an interview on 10/4/21 at 4:25 P.M., LPN A said: - He/she was the resident's charge nurse on 10/2/21 from 7:00 A.M. through 7:00 P.M. - Around lunch the resident complained of right leg and knee pain while the resident was sitting in the dining room. - LPN A applied the resident's ordered prn Biofreeze and Tylenol. - LPN A did not remove the resident's tight fitting pants and did not assess the resident's leg. - The resident kept rubbing his/her leg. - The nurse applied the Biofreeze on the lower leg up to the knee where he/she could reach. - LPN A asked the resident if the resident thought the pain was due to cramping. - The resident told LPN A that he/she thought the pain was due to cramping. - LPN A should have viewed the resident's leg for an assessment. Review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M.: - He/She administered Tylenol 325 milligrams (mg) two tablets for mild pain using pain scale 1-10 (with 1 mild pain and 10 maximum pain); - Follow-up administration was ineffective and pain still a 3; - No notification of charge nurse was noted. During an interview on 10/4/21 at 4:20 P.M., CNA B said: - He/she worked 10/2/21 at 3:00 P.M. until 10/3/21 at 7:00 A.M. - The resident was in a lot of pain the entire shift. - Whenever CNA B tried to roll the resident, the resident would cry out in pain. - CNA B notified the charge nurse of the pain around 9:00 P.M. Review of the resident's Situation, Background, Assessment, and Request (SBAR), dated 10/2/21 at 9:00 P.M., showed LPN C documented: - The resident had increased pain, swelling, and warmth to the right knee. - Turning, raising, attempting to straighten the knee increased the pain. - LPN C notified the Nurse Practitioner (NP) on call. Review of the resident's nurses' notes by LPN C, dated 10/2/21 at 9:19 P.M. showed: - Staff reported to LPN C that the resident complained of increased right knee pain. - Assessment by LPN C showed the resident could not straighten the knee, with swelling, warmth, and redness of the knee. - LPN C notified the NP and the Director of Nursing (DON) on call. - LPN C applied the resident's ordered Biofreeze and administered ordered as needed Tylenol. During an interview on 10/4/21 at 5:17 P.M. LPN C said: - He/she was the charge nurse on the night shift starting 10/2/21 at 7:00 P.M. through 10/3/21 at 7:00 A.M. - When the resident complained of knee pain, he/she applied prn Biofreeze and administered prn Tylenol. - The resident was comfortable at rest, but quite uncomfortable when moved. - He/she notified the on call NP around 9:00 P.M. on 10/2/21. - The on call NP called back around 1:00 A.M. on 10/3/21 and said he/she would speak with another NP about ordering an X-ray. - The on call NP called back around 4:00 A.M. with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] - When he/she assisted the CNA with turning the resident the resident moaned in pain during cares. During an interview on 10/4/21 at 5:05 P.M., CNA D said: - He/she started work on 10/2/21 at 3:00 P.M. and finished working on 10/3/21 at 7:00 A.M. - The resident stayed in bed due to pain. - The resident seemed like he/she was in pain when the resident moaned and rubbed his/her thigh. - He/she notified the charge nurse the resident was in pain and he/she did not see the charge nurse assess the resident. Review of the resident's nurses' notes, dated 10/3/21 at 4:52 A.M., by LPN B showed: - The nurse practitioner called an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . - LPN B notified the mobile x-ray provider. Review of the resident's nurses' notes, dated 10/3/21 at 11:43 A.M., by LPN A showed: - X-ray report showed displaced fracture (a break in the bone when the pieces of the bone did not line up) involving the right femur (upper leg bone); - The on call NP gave an order to send the resident to the emergency department. During an interview on 10/4/21 at 4:25 P.M., LPN A said: - On 10/3/21 the resident stayed in bed all day due to pain. - On 10/3/21 a mobile X-ray was performed that was ordered by the resident's NP around 4:00 A.M. due to leg pain. - On 10/3/21 LPN A called the on call NP with the X-ray report that showed the resident had a femur fracture. The NP gave an order to transport the resident to the emergency department. LPN A had the resident transported to a local emergency department (ED). - LPN A said he/she should have thoroughly assessed the resident's leg when the resident reported pain at noon and he/she should have promptly reported the change in condition to the resident's NP on call. Record review on 10/4/21 showed staff did not document vital signs and assessment every shift following Resident #1 being lowered to the floor by staff. Review of the resident's medical records from a local hospital, dated 10/3/21 at 11:46 A.M. showed: - Chief complaint right leg pain. - The resident was noted to have increased pain in his/her right leg. - The resident had increased confusion. - There was no report of trauma. - The resident rated the pain as an 8 on a 1-10 scale. - Assessment showed a right femur fracture with intractable (pain that was unrelenting) pain due to the femur fracture. - X-ray report showed a displaced femur fracture. - The resident was taken to surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 10/5/21 at 9:55 A.M., the DON said: - The charge nurse should consider a fall as any time a resident was lowered to the floor. - Staff should thoroughly assess any resident after a fall. - Staff should thoroughly assess any resident with any change in condition. - Staff must chart vital signs and an assessment every shift for 72 hours after a fall. -He/she expected that staff would have notified the PCP and family after the fall. 2. Review of Resident #2's significant change in condition MDS, dated [DATE], showed: - Memory problem with moderate cognitive impairment; - Total dependence upon staff for cares; - Used wheelchair; - Always incontinent of bladder and frequently incontinent of bowel; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - Two or more falls with injury. Review of the resident's care plan, dated 10/2/21, showed: - The resident was at risk for falls related to physical and cognitive deficits. - Remind the resident not to lean forward and sit up straight and lay down if the resident cannot stay awake. Review of the resident's nurses' notes, dated 10/2/21 at 7:07 A.M., by LPN C showed: - Witnessed fall. - The resident was sitting in his/her wheelchair, with his/her head resting on his/her chest. - The foot pedals were in place and the resident was wearing gripper socks. - Staff observed the resident slide off the chair on to the buttocks. - The resident did not hit his/her head. - No obvious injury. - Range of motion (did not specify what limbs) performed with no pain. - No documentation of notification of NP and responsible party. During an interview on 10/4/21, PTA A said: - He/she saw the resident on 10/2/21 in the morning. - The resident's ankle appeared swollen. - PTA A reported the issue to the charge nurse. During an interview on 10/4/21 at 4:55 P.M., LPN B said: - The resident fell out of his/her wheelchair during change of shift report on 10/2/21 around 7:00 A.M. - The resident fell on his/her hands and knees with feet caught under a chair. - The resident used to have a Broda (a chair that kept a resident in a back tilted position) and hospice removed the Broda chair. - The resident just improved enough to be discharged from hospice. - The resident would lean forward and kept leaning further forward until he/she fell . - The resident did not complain of any pain after the fall. - The resident's left ankle appeared puffy and deformed, but the resident's spouse said the resident's ankle always looked different. - LPN B called the resident's NP the morning of the injury, who ordered an X-ray. - LPN B ordered the X-ray, but the mobile X-ray did not arrive until 10/3/21. - The resident complained of left ankle pain most of the shift. Review of the resident's nurses' notes, dated 10/2/21 at 6:02 P.M., showed: - The resident complained of ankle pain with swelling. - Staff notified the resident's NP and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's nurses' notes, dated 10/2/21 at 9:10 P.M., by LPN C showed the mobile X-ray called and said the X-ray would be performed in the morning. Review of the resident's nurses' notes, dated 10/3/21 at 12:49 A.M., by LPN C showed: - Swelling to left ankle; - No complaints of pain; - Resident resting quietly in bed; Record review on 10/4/21 showed staff did not document vital signs and assessment every shift after Resident #2 fell from his/her wheelchair and had pain and swelling to his/her left ankle. Review of the resident's ED report, dated 10/3/21 at 11:19 A.M., showed: - Resident brought to the ED for increased confusion. - The resident had received hospice care until a week ago when the resident improved and hospice was discontinued. - The resident fell from his/her wheelchair sometime on 10/2/21. - The resident was only responsive to painful stimuli. - diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - Treat the [CONDITION(S)] and splint the fracture in the ED; - If the resident's mental status did not improve would discuss hospice care with spouse. Review of the nurses notes', dated 10/3/21, showed no charting regarding when the resident was transferred or why the resident was transferred. During an interview on 10/5/21 at 9:55 A.M., the DON said: - When the resident was discharged from hospice, hospice took the Broda chair. - Staff should have assessed the resident every shift after a fall for pain and swelling. - The resident was an increased fall risk, because the resident did not ask for help. - Staff should have notified the resident's physician or NP after the fall. 3. Review of Resident #4's quarterly MDS, dated [DATE], showed: - Severe cognitive impairment; - Required extensive staff assistance for cares; - Used a wheelchair and a walker; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, dated 8/31/21, showed: - The resident had limited mobility due to a stroke; - The resident received blood thinners and was at risk for bleeding. - No care plan for falls. Review of the facility self report (FSR), dated 10/6/21 at 7:49 A.M., by the ADM showed: - A CNA was assisting the resident to bed on 10/5/21. - When positioning the resident, the resident's head hit the head board. - The staff member notified the charge nurse. Review of the resident's nurses' notes showed no notations for 10/5/21 and no notes regarding the resident hitting their head on 10/5/21 and no documentation of any assessments after the resident hit his/her head. During an interview on 10/6/21 at 2:00 P.M., Registered Nurse (RN) A said: -The resident told RN A that a staff member hurt him/her when the staff bumped his/her head on the head board. - He/she did not chart the resident's allegation of injury after the resident told him/her that staff injured him/her. - He/she did not chart a post injury assessment. - He/she should have charted the resident's allegations of injury. - He/she should have assessed the resident post allegation of injury. During an interview on 10/6/21 at 2:05 P.M. the DON said: - Staff should chart an allegation of injury. - Staff should assess any resident after an allegation of injury. - Staff should immediately assess any resident after a fall. - Staff should assess each resident every shift for 72 hours. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 9, MO 8, MO 6, MO 1, MO 6

Based on interview and record review, the facility failed to ensure that two residents (Resident #1 and #2) received treatment and care in accordance with professional standards of practice when Resident #1 was not sent to the hospital as ordered by the physician, and Resident #2 was sent in error. The residents' room numbers were switched and incorrect in the electronic medical record. The attending nurse was not aware of the error, and unfamiliar with both residents. Resident #1 was later found expired and Resident #2 was wrongfully subjected to testing at the hospital emergency department. The facility census was 78. The administrator was notified on [DATE] at 1:00 P.M., of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on [DATE]. On [DATE], the administrator became aware Resident #2 was mistakenly transferred to the hospital emergency department. Administration immediately performed room audits on all resident rooms, ensured all residents had door signs, ensured all residents had photo identification in their electronic medical chart, inserviced nursing staff on room assignments and how to update room numbers in the electronic medical chart and to notify supervisor if error identified, and implemented a secondary check on all room changes for accuracy. The IJ was removed and corrected on [DATE]. The facility did not provide any policies requested. 1. Review of Resident #1's quarterly minimum data set (MDS, a federally mandated assessment completed by facility staff), dated [DATE], showed: -Brief Interview Mental Status (BIMS) score 4. Indicating severe cognitive impairment. -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, dated [DATE], showed: -History of [CONDITION(S)]. -[CONDITION(S)]. -Impaired cognitive status. -Stage 3 kidney disease (moderate kidney damage present). -Communication problem related to [CONDITION(S)]. -Alteration in neurological status related to [CONDITION(S)] (a weakness and rapid fatigue of muscles under voluntary control, the condition is caused by breakdown in communication between nerves and muscles) disease process. -COVID-19 ([CONDITION(S)]-CoV-2 coronavirus causes COVID-19, a respiratory illness) positive. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -No order to send the resident to the emergency department for evaluation. Review of the resident's radiology reports, dated [DATE], showed: -Abdomen series (set of abdominal radiographs obtained to evaluate bowel gas) scan performed due to abdominal pain. -Multiple dilated small bowel loop seen and findings may be secondary to ileus (nonmechanical obstruction of bowel) versus small-bowel obstruction (mechanical obstruction due to adhesions, mass, or other internal or external compression). Follow up computed tomography (CT, a combination of x-ray images taken from different angles around the body and uses computer processing to create cross-sectional images of the bones, blood vessels and soft tissues) scan is recommended. Review of the resident's nurses notes, dated [DATE], showed: -At 6:00 P.M., administered pain medication. -At 9:34 P.M., resident has an order to be sent to the emergency department for further evaluation. Upon entry to room, resident was unresponsive. Do Not Resuscitate (DNR) status confirmed. -At 11:20 P.M., on-call provider returned call back for resident to be released to funeral home of family's choice. Time of Death: 9:30 P.M. Review of Resident #2's quarterly MDS, dated [DATE], showed: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's POS, dated [DATE], showed: -No order to send the resident to the emergency department for evaluation. Review of the resident's care plan, dated [DATE], showed: -Potential for pain related to [CONDITION(S)] -Impaired cognitive function/dementia or impaired thought processes related to Lewy Body dementia (second most common type of progressive dementia, protein deposits develop in the nerve cells in the brain regions involved in thinking, memory and movement). -Communication problem related to expressive [CONDITION(S)]. -History of [CONDITION(S)]. -COVID positive. Review of the resident's nurses notes, dated [DATE] and [DATE], showed: -No documentation of transfer to the emergency department. -No documentation of return from the emergency department. Review of the hospital emergency department records, dated [DATE], showed: -Patient denies that he/she is here in the hospital. -COVID test performed at 9:25 P.M. -Blood draw performed at 9:31 P.M. -RA Acute ABD Series (common set of abdominal radiographs obtained to evaluate bowel gas) completed at 10:08 P.M. -Urinalysis (UA, urine test used to detect and manage a wide range of disorders) collected at 10:10 P.M. -At 10:20 P.M. the charge nurse notified staff that the wrong patient had been sent. During an interview on [DATE] at 9:32 A.M., Family Member A said: -He/she was concerned for Resident #2 and the effect of the hospital visit. -Resident #2 has dementia and cannot communicate/express feelings. During an interview on [DATE] at 11:55 A.M., the Administrator said: -Resident #1 should have went to the hospital, but Resident #2 was mistakenly sent in error. -Resident #1 was in room [ROOM NUMBER], but the computer showed room [ROOM NUMBER]. -Resident #2 was in room [ROOM NUMBER], but the computer showed room [ROOM NUMBER]. -Both residents were moved to the designated COVID unit on the evening of [DATE]. -Unit managers are usually the ones responsible for changing the room assignments in the electronic medical record. All nurses can make this change/update. -Licensed Practical Nurse (LPN A) had never cared for Resident #1 or Resident #2 before. -Thirty minutes passed between Resident #2 being sent with emergency medical services (EMS, ambulance service that provide transport) and the error being identified. -Hospital was made aware of the error and Resident #2 sustained no treatment or procedures. Review of a signed statement by LPN A within the facility investigation, dated [DATE], showed: -Upon start of shift, asked to notify physician regarding x-ray results. X-ray sheet read Resident #1 in room [ROOM NUMBER]. -Called on-call physician at 8:15 P.M. and at 8:25 P.M. received order to send to hospital for further evaluation and prepared for room [ROOM NUMBER] transport. -EMS arrived at 8:40 P.M. -At approximately 10:05 P.M., he/she and LPN C entered room [ROOM NUMBER] and found the resident expired. Further review identified this resident as Resident #1. The computer showed the room numbers for Resident #1 and Resident #2 switched and incorrect. Review of a signed statement by LPN C within the facility investigation, dated [DATE], showed: -At 9:30 P.M., while preparing medications, LPN A stated the resident picture for room [ROOM NUMBER] looked like the one transferred out. Upon entry to room [ROOM NUMBER], the resident was found expired. Another staff member familiar with the resident was called over to verify identity. -Resident #1 was listed as room [ROOM NUMBER] in the electronic medical record and Resident #2 was listed as room [ROOM NUMBER]. However these room numbers were switched. During an interview on [DATE] at 9:20 A.M., Physician A said: -Resident #1 and Resident #2 looked similar. -He/she and the nurse practitioner both assessed Resident #1 earlier that day. During an interview on [DATE] at 4:00 P.M., LPN A said: -Upon arrival to start shift, the prior nurse said that the resident in room [ROOM NUMBER] had a x-ray result that showed possible bowel obstruction. Resident #1's name was on the report, however the room number on the report was assigned to Resident #2. -The provider was notified and ordered further evaluation at the emergency department. -Notified family and EMS. -Went into room [ROOM NUMBER] and checked on the resident, ensured the resident was ready for transport. -Provided report to EMS in the hallway outside of the resident's room. -Due to cognitive impairment, the resident was not able to verify identity. -One to two hours later, found resident in room [ROOM NUMBER] expired. Upon verifying code status, realized the mistake and that wrong resident was sent to hospital. -He/she never cared for Resident #1 or #2 before, and did not know the room assignments were incorrect. -Resident #1 and Resident #2 looked similar. -Resident #2 had blood drawn while at the hospital. During an interview on [DATE] at 8:52 A.M., LPN B said: -There were so many room changes the day Resident #1 and Resident #2 were moved to the COVID unit. -Did not know what happened to cause the room assignment error. -Did not realize the room assignment error. He/she cared for Resident #1 before and could recognize him/her. -Not positive if the residents' names were on the door. During an interview on [DATE] at 1:00 P.M., the Administrator said: -The hospital reported that nothing had been done to Resident #2. -On [DATE], the hospital called to report Resident #2's COVID test result obtained on [DATE]. -Did not know Resident #2 was subjected to blood draws, radiology scans, or a UA. MO 4

Based on observation, interview, and record review, the facility failed to ensure that one resident (Resident #1) out of four sampled residents was free from mental abuse when a staff member used his/her cell phone and video recorded the resident in the shower room and posted the video to Snapchat (a popular messaging app that lets users exchange pictures and videos that are meant to disappear after they are viewed). The resident who is blind and hard of hearing was unaware of the video. The resident was naked and his/her body was exposed from the head to the knees in the video. The facility census was 75. The administrator was notified on 6/5/20 at 3:15 P.M., of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on 5/29/20. On 5/29/20, the administrator became aware of the violation of the facility Abuse and Neglect, and Phone Usage policy. The facility suspended the CNA and in-serviced the staff on Abuse and Neglect, and Phone Usage policy and procedures. The IJ was removed and corrected on 5/30/20. Review of the facility policy, Abuse, Prevention and Prohibition Policy, dated January 2017, showed: -Each resident has the right to be free from abuse. -Residents must not be subjected to abuse by anyone. -This facility prohibits mistreatment, neglect or abuse of residents. -The facility will educate all employees upon hire and at least annually of the definitions of the Abuse Prevention and Prohibition Policy. -In-services may include differences between violations of resident privacy and mental abuse; taking pictures or recordings of residents without the residents' responsible party's consent is a violation or the resident's right to privacy. -Abuse prohibition will be reviewed and discussed at least quarterly to verify staff knowledge and awareness of the plan. -Mental abuse includes but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident. Review of facility Cell Phone Usage and Social Media policy, not dated, showed: -The possession or use of cellular phones is strictly prohibited while on duty. Use of these devices will be restricted to the break room or outside of the facility. -To ensure the privacy of residents, their families, and fell ow team members, the taking of photographs or audio recordings on facility property is strictly prohibited without the explicit permission of the Administrator/Executive Director. -Prohibited activity includes: the use of social media while on duty, any information that violates privacy standards, unauthorized disclosure of resident information that violates the Health Insurance Portability and Accountability (HIPAA), resident rights, and facility policies. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 4/27/20, showed: -Wears hearing aids and has severely impaired vision. -Brief Interview for Mental Status score of 15; indicating no cognitive impairment. -Required one staff assist for dressing and personal hygiene. -[DIAGNOSES REDACTED]. Review of the resident's comprehensive care plan, dated 5/29/20, showed: -Resident was legally blind. -Resident was hard of hearing. -Resident had [MEDICAL CONDITION] depression: dated 11/14/18. -Resident required one staff participation for bathing/personal hygiene: dated 11/14/18. -Resident had suffered a traumatic life event, physical assaults from domestic violence: dated 11/27/19. Review of nurses' notes, dated 5/29/20 at 10:21 P.M. signed by the Director of Nursing (DON) showed: -Visited with resident regarding incident that happened in the shower with employee, explained what happened and offered support, notified next of kin, implemented two staff present for showers at all times, sent in-house psych referral, notified medical director, and will offer ongoing psychosocial support. Review of the undated video recording provided by the facility on 5/30/20 showed: -Video posted to Snapchat and was forty-three seconds in length. -Text across the video screen showed He/She has made me so tired just talking. -Certified Nurse Assistant (CNA) A and the resident in the shower room. -The resident was exposed from his/her head to his/her thighs. -At 00:00 seconds, CNA A starts the recording and steps back beside the resident. The resident was standing up, with no clothes on, and was exposed from his/her abdomen up to his/her head. -At 00:12 seconds, CNA A turned the resident to face the camera. CNA A looked into the camera while holding a towel and dried the resident. The resident stood with arms up and slowly turned slightly to the left. -At 00:27 seconds, CNA A picked up an adult soiled brief or underwear that was discolored, showed it into the camera, shook his/her head and smiled. -From 00:31 seconds to 00:43 seconds, showed the resident standing in the shower room exposed, with his/her left side facing the camera and slightly moving his/her upper body back and forth. CNA A is not visible in the video during this time. During an interview on 6/1/20 at 8:47 A.M., Dietary Staff Member A said: -On 5/29/20 evening, while off duty, he/she opened Snapchat and could see the resident in the circle of CNA A's story (where a picture or video can be posted on social media and viewed by friends for up to twenty-four hours). When he/she opened the story, it showed CNA A and the resident. The resident had no clothes on in the video. CNA A turned the resident towards the video and then took the video and walked around the resident, spinning the resident. CNA A also pulled the resident's brief or underwear from the floor showing that it was dirty. -The story timeline showed it was posted forty-four minutes prior. -He/She immediately used another phone to record the video in order to save a copy, notified the facility administrator, sent the administrator the video and then deleted it. -The resident is blind and cannot see. -It is against facility policy to put residents on social media or videotape them. -He/She had never seen anything like this before on Snapchat. -He/She felt shocked that someone would post a video like that. -He/She was unable to report the video to Snapchat before CNA A blocked him/her, however the DON was able to report the video. During an interview on 5/30/20 at 8:09 A.M., the facility Administrator said: -On 5/29/20, off duty Dietary Staff Member A reported a video on Snapchat of the resident by CNA A. -The video was reported to Snapchat. -He/She had a copy of the video. -CNA A was suspended and will be terminated. -CNA A admitted he/she recorded the resident and posted it to social media. -All staff were immediately in-serviced regarding Abuse and Neglect, HIPAA, and Videotaping. -Two staff are required to assist the resident with showers effective immediately. -The resident is blind. During an interview on 5/30/20 at 2:00 P.M., the resident said: -The Administrator and DON notified him/her last night of a recording performed by a staff member in the shower. -He/She felt upset, surprised anyone would do that, kind of scared, and kind of shook up. -It's a terrible feeling, scary, when one cannot see or hear. -It caused a terrible nightmare last night, it felt so real; he/she woke up fighting the mattress. -Earlier this morning he/she broke down crying in the bathroom; his/her nerves got the better of him/her. -It affected him/her mentally, physically, and emotionally. -He/She cannot get rid of the feeling of CNA A coming after him/her. -It puts a scar on you; something you do not get over overnight. -It makes you want to isolate yourself. During an interview on 6/2/20 at 9:00 A.M., CNA A said: -On 5/29/20, he/she recorded the resident after a shower at 7:00 P.M. -On 5/29/20, at approximately 8:00 P.M., the administrator called him/her to their office and confronted him/her about the video, informed him/her of suspension and was escorted out of the building. -The resident did not know he/she was being videotaped. -He/She knows the facility policy and that cell phones are not allowed during work and videotaping is not allowed. -He/She is upset that he/she videotaped the resident, knowing that it should not have happened; he/she knew better. -He/She takes full blame for his/her actions. -He/She posted the video on Snapchat. -He/She knew it was not right and not funny; performed the recording out of boredom and for entertainment. During an interview on 6/2/20 at 9:22 A.M., Family Member A said: -On 5/29/20, the Administrator and DON both notified him/her of the video recording and that the police and state agency were notified. -It was disturbing to hear. -The resident is blind. Throughout multiple interviews, starting on 5/30/20 and a final interview on 6/5/20 at 3:00 P.M., the Administrator and DON said: -CNA A was suspended immediately and will be terminated from his/her employment at the facility. -A police report has been filed and next of kin were notified. -Effective 5/29/20 all staff were in-serviced and the resident had two staff assisting with all showers. -The resident is receiving one on one visits by nurses as well as social services; -The resident's counselor and psychologist were contacted to set up visits. MO 794